HomeMy WebLinkAbout012-739-02-2308-SAN-2022-180 '`� � � Department of Safety c°"nry � �
� � - & Professional Services, Sanitary Permit Num r(te Ue filled in by C Z
� �, S
� �` i ;� Industry Services Division
� � � t � � �
Sanitary Permit Application State Trensaction Number �
L�accordance with SPS 383.Z1(2),Wis.Adm.Code,submission of this form to the appropriate govemmental unit � 1
is required prior to obtaining a sanitary perrnit Note:Application forms for state-o«med POWTS are submitted to Project Address(ifdifferent than mailing adi �-
the Department of Safety and Professional Services.Per;onal information you pro��de may be used for secondary , �� �i_ .� �+ �
purpases in acwrdance«rith the Privac}'La�v,s.i�A4(!xm),Stats. ���Q� u' ti'�l/
I.Application Information-Please Print AlI Information � ��
Property Owner's Name Parcel#
�v.�Cia � f C?t�- ?39'-0�---�3v$
Property Owner s Ylailing Address Property Location
a �!"1 , �s�,�
City,State Zip Code Phane Number
/l�L��(Yl ' �{C.�'�L 0 � " l a2' �-�.e�l —5��'! �w �'. N w �/,, se�uon r?�
II.Type oTBuitding{check ali thaf appl��) Lot# T 3� N R �� E or
�i or?Fami}y ihvclling-Number of Bedrooms �____ Subdi�ision Nan�e�_
Block� �
❑PubliclCommercial—Describe[Jse
^ ❑City of
O StaEe Owned—Describe Use CSM Number ❑Village of
r- C�,Town of�l.n,`��� _
III.Type of POWTS Permit:(Check either"New"or"Replacement^and other applicable on line A. Check one boa on line B.Complete line C if
a licable.)
A.
❑ Ne�v System �Replacemeat Systetn ❑Other i4Foclification to Existing System(expiain) ❑Additiona!Fretreatment Unit{explain)
S.
❑Holding Tank (�,ln-Grontxl ❑At-Gride ❑ Mound ❑ Individuai Sitc Design ❑Other"fype(eacplain)
(cam�entional)
C• ❑Renewai Before ❑ Re�ision ❑ Change of I'3umber ❑Transfer to New Owner �����ous Permit Number and Date lssued
Expiration ��_ I�� lO '
IV.DispersaUTreatment Area and Tank Information:
Design!►o��•(�d} I)esign Soii Applic-ation Ratc(�Qd'st) Di:pecsal Ana Required(s� Di�persal Arza Proposed(sfl System Ele�ation
�3, 5�
Capacity in Total �of Manufaccurer
Tank Infonnation Gallons Gailons Units Q � o � �
Ne�;�Ta�tks U ,
Existinc Tanl;s � � � ,
a�. � � u�- � .f � c'�S
— �J C/] n V1 Cz. v �-^�+
Septic or Noiding Tank
!� Q ) ( � �5�4 �
Uasing Chambcr
V.Respon5ibilih Statement— I,t6e undersSgned,�ssame responsibilitt�for installation of the PO«`'TS shown nn the attached plans.
Plumber's Name(Pri�E) P1 ' Sienature MPI"MPRS Number B�ine��Phoi�e\uminr
� r/t —
P umber s Address(Street,City,State,`Lip Code) ������ ` J �b�'
� � �' " �L���f-�� �l� y�[ -l�-
VI.County/Department Use Only
� �' ❑llisappro�•ed Percnit Fee Date Issued Issuine Agent Signatum
❑Owner Given Reason lor Denial ���„� �(3�a a �
Canditions of ApprovaUReasons for Disapproval
,__.� . r-:�-^,�
D ��l(��,�,�, ' ' ''`i
�' Date g N ��- x�.___ ._ _ - ,�_�,��� w, ,
G ;�
IN
� 50 __
cnk# � � �uL 2 s 2022 �--�
CS� aZ� - ��(o Rcpt#N'e�� w�r1�1�.�.��1, �
� ��� ZQNM!(�ADMIIS STE�ATION
` Attach to complete pla¢s fnr the system and submi�to ihe Couaty only on paper not►ess than 8 1/2 x ll inc6es in size '
NO REFIINDS AFTER
SBD-6398(R.03'22) ISSUE OF PETy1A1'i'
�`"/b.S�i
PAGE 1 OF 4
In-Ground Gravity Plan
Index & Cover Sheet
Component Manual Design References:
In-Ground Soil Absorption for POWTS Version 2.1 (May 2022-2027)
Pg 1 of 4 Index & Cover Sheet
Pg 2 of 4 Plot Plan
Pg 3 of 4 Dispersal Area Cross-Section & Plan View
Pg 4 of 4 Management Plan
Attachments: Enclosures:
POWTS Application for Review
Soil Evaluation Report & Site Map
Project Name / Description
Owner Name(s): G,Qy�/�.��-. �'rv1'i/1 SucY�� ��c.� `��f Phone: �ca -�o� -5a�g
Owner Address:;�b�-� �r�,� Lv�1 �fxr1,��h (�Cwk-��L- Zip: {,�4l3�
Project Address: 1(�.�j C�(01,v �d� l:-4t�.+� � �u�Cc.bt�L � c�,�j��-,�
Govt. Lot: ���1/4 of �41� 1/4, Section�, T��N-R 07 E❑or W Q
Township: ��cu,l°�,��1"� County: ��C'�t..�,d�'
Project Parcel ID #: � (,�.��3Cf� C7�-- vZ30�
Designer Information
Designer Name: ��1L�.d1. �1i'�1c..I'� Phone:��5 S$�S -l(��_
Designer Address: �(��"7� l�`Tl►U- � Gc.QpCc�k-2e9, ��iP: 5�-��
E-mail: �� ,
License Number: ���?�/
Remarks:
Si natur • � —
9 e• Date: ���..7 �o-�
O� inal sign t required on each submitted copy.
State of Wisconsin
DEPARTMENT OF NATURAL RESOURCES Tony Evers, Governor
101 S.Webster Street Preston D. Cole,Secretary
Box 7921
Madison WI 53707-7921 Telephone 608-266-2621
Toll Free 1-888-936-7463 WISCONSIN
TTY Access via relay-711 DEPT.OF NATURAL RESOURCES
;�\
"�I)�G;;
,
August 3, 2022 rfil�\��t�,�
�, �� -"� �����' �
��, _ �,`�f
Sav�ryer County Zoning and Conservation Department ` 03 �
10610 Main Street, Suite 49 �`, �y�k�,;:�,iM1� �.`���'? �
Hay�vard WI 54843 ' ^-' �'
'',-.
,�, tJ
Dear Sawyer County Zoning and Conservation Department: �
[ have reviewed the POWTS permit application submitted for the property located at 10506W County Hwy CC in
the To�vn of Hunter, Sawyer County, Wisconsin. The property is fiu-ther identified as having Sa�ryer County Tax
iD#14504.
This property is not covered by a Chippcwa Flowage buffer�one restriction.
All other county and state codes and permits apply to the subject property and must be applied for and adhered to.
Please coutact me if you have any questions.
Sincerely,
___-_ C���,��
Roy Kcnast
Chippewa Flowage Property Manager
715-634-7433
d n r.wi,g ov ��PqIN1FD
wisconsin.gov Naturally WISCONSIN °"AEc"E`
YAPER
tJ'u: E�"'- �
Sauvt�s��mrc�c� 54ck.� Re�Tr�s-4- Saw�ev- Co� Hv.,�'e.•-Tw�.
3ozz tlde� ?� {��rJ: GtZ-'�34-OZ-Z3DQ;
�v'a��l�� {� r�C�SL (oDl3� SG�/tJW � DL T3R^� R D� W
f-3�z_4oK_sZiq s:��= IoSo�Ow Co �Fw� ��CC"
� ��y��s S(o�gG�-�—
_� �
�, ,
� �
� ��± I�S�� --- �
l� S�e �`�_�Fo'
� �� N
S�ee� �_
�— � �
� o ,o zo � wn.
�,��s:� �a C�n-���
i
�
_ Ex Z6�
;� ♦Sruoo ro� o�tale[�
�
+� p�op l B 1. 4�.23'
Li h�� I � Z, q7.�1'
� � i
3_ R�.I4`
0 I
� St�l��o ,(�Sd,�S�5�.e l. 43.$�
� I - �w�ll C r4•.12. �t 2.5�—4Y'�
3 4 4 _„�so��'c
a 9 ye — £s-F ST.;n1 a5.5�
Lg�
.3 • gu�z
n�
� _v
� a
� •z
� b
� �p 5
s �
� �lD�O(�jw Ca !�w CC
I
- } =� j= �a�� 3 a� � .
^ � _ _ ,
� _ ��
� _� _ _ _
; i � i= �- `J �
; � ! � �,= F✓ � - �
; .. � � � v ._ � �
� i P . r ? i`I : -_�� �
� J Q j , � � . +� ....�i.�.. ,`..� �
V � � � I � j � �j : : 1'. -r.
� C ; � � } � l.i •j - v: >i,�J . � �
i � � i � z �'�:..: .. ! =J,;l �=- � �
' � .x �, ; Q i ( . : ..�-? Q = c` U.
t "� :,. " , t L,�-_. : ^ ' _ _' _ ' 1� ?` X f �
�' � � � T- - = - - ' � L' �
: � � ,�`__j ` � � ' j - = x = - �'a _ � -� �= J:
� ' � j x �f c " � z�.. _ � ',+^ {f, ^ �� �i
�� ... �% i �v C `t �` I ���3 9 v �,� �` C �� �
,' � � s t �_ ` �i � �t j j? � N � =" �i\� ��
� r � �v � ; ` ,� , ,� � ^ � ,
i� s ;; � ;' : i� � :1; _. „ �
� � , :� �
. �\� L � � f ' �j I �� � '� ( v r
v ( ll 1�
� � G ' ;i � ii � �t i � ".. /
\
r - � i� � j! i 3� . �`r �
J � � � i; j �. _ ,��
wz � r: f
a J � � - '' f �� ,: � - � ;c
� � C�I � �' _ — :`` � �� { `' C
� 1— f— � = 3 = � ? ': � i j �' ` — :—
'� � (1 � '� � - 3 ^ _ , � �; ' ! ? = �
� -�rti? O c = ^ - = 'c � � �: � ' ; � c�
z � �
� v � � � � � ^ !� � �� ' fl t L � �.
rrt V� ' � � �` ,I i �
� � L� v} L tv j _ _ {'v li � �� � !t i � +^+ �
p� � L � �1 � :1 � V J
Lit 1.1� � � � V - ^ i +' ' M L �
f-�- a � � _ � ''•� i �- z
Cr " ' _ • „ .
_ ,.�.�.. j Lr :r. -o _ i; i ;1
� � Z3 �' U _ " s I �
__,j � sQ._? � :,.= - � � ? C
� �.. U ; � , � . ' ;
� N �' _ v , ' c i ; ,� . ! .; J
� �. .,.
. = i i "a
� � � �; � � � , a� ; 1 � = �� �� ' � °
1�-! .� N �_; — � e = • . v� `' �1 v`� �^ �
� = r�!� . � ; TV _ '
.� � . �
r , c � � � �
(� �� � �"' � !! � ^` ' � I
� � I � � ' y ( ;• _ _ y � � t� il !I i It X
� � � � • ' _ � _ � \ CC ` •� i =
� � p � �� � � � ; , � � f c
� � ` _
�y � �; ; — - '� j < E �
}-- �,,,� = � � � ! : , V? G7 1 �.
� �^, � i \ = L `� ' j' .� `� : �:
W �t � " � � t . i? , � 1� � � �
� ,L � , C ? � {` 1�1 � � �^ � U'
� {� � '1 ; ^ ^ 1. ! � „ , j '��� 1) Cti �
ir � � '�-- — — -� ? :; J3 ,� ' �i � f� I �� V � ' �
O� � � � — � . , . 1J � �'�i �i ��J� � �; '� C7 j C
� �}�al � i X j _ - � � v :� i i� i �I � '� L � �
i ... ,\ ,'•..�•' �r i 't C �t I �� ..�. � ! n
� � I � �j r. T � . i , t �, ..^.. ..^.. ! .�
� T r ii f
� (� M ;% ` " � T i{ 1 �: � s � -' � i!
j :. � � : �' W j , `;—
� �1 �� I •, , !' �� O y/J �
� � � � �� � �� �� r�
� � 5 � i � „ � i �f , ,
�a/ t j � � U �% !: . �i"'_�� ` `� � �i
t � �. � ;i � �: : ': ' {iJ i � p
:t i �
� � c ¢ � Z ; � j: ; � i Z� , f ;
_ � � �, —�
� :�; `-� � ,,,, � , :� I : � .
.�-r,�: �' `f'�s^J�� �
I � I f r-t �
PAGE 4 OF 4
In-ground Gravity Management Plan
IMPORTANT:
The owner of this in-ground gravity system shall be responsible for its perpetual operation and maintenance pursuant to
requirements of SPS 382-384,Wisc_Admin.Code. Pursuant to SPS 383.52(2),Wisc.Admin.Code,this system shall
be considered a human health hazard if not maintained in accordance with this approved management plan.
Furthermore,all inspection and maintenance adivities shall be performed by a registered POVYTS Maintainer in
accordance with SPS 353.52(3),Wisc.Admin.Code.
Maximum Dispersal Area Operating Limits:
Design Flow= �/S� gpd; BODS<_220 mgL"'; TSS<_150 mgL"'; FOG<_30 mgL"'
Insaection 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 solids volume in anaerobic treatrnent tank(s)and any distribution appurtenance(s)(i.e.,distribution/drop boxes)
o neglect or improper use(i.e.,exceeding design capacities,prohibited adivities,etc.)
o extent of ponding in distnbution cell prior to dosing
o dosing irregularities-if applicable(i.e.,pump re-cycling,float switch settings,etc.)
o electrical components-if applicable(i.e.,wiring,connections,switches,controls,timers,alarms,etc.)
o distribution lateral or lateral orifice plugging (measure lateral distal pressure—compare to design specification)
o surface discharge of effluent or sewage back-up into structure served
Maintenance Checklist MAINTAIN EVERY 3 YEARS(or when necessary)
o Seotic and dose ta�k(sl shall be pumped by a certified septage servicing operator licensed under s.281.48 Wis.
Stats.when the volume of solids in the tank(s)exceeds one-third(1/3)the liquid volume of the tank(s)or
as required by local ordinance. Disposal of contents shall be pursuant to NR 113,Wisc.Admin.Code.
o Effluent fiiter(s)shall be inspected every 3 years and shall be deaned when necessary to remove any
accumulated solids according to manufacturer's specifications. A servicing period will always be greater than 12
months.
System maintenance reports shall be submitted to the proper local government unit in accordance with
SPS 383.55 Wisc.Admin.Code. Report any component failure or malfunction to:
Name of individual or company:��CJ�./11 _3�v(,t.Y`ES� Phone:����S�—{��T�
Local govemment unit: �(1!A��(9� A ��(]�� Phone:���--�iE�LQ��
Local govemment unit address:�l�j���il,Y���" ����? � Yi1L�, ZIP:�l.�c��_
Any defective part of this system shall be repaired,replaced,or removed pursuant to SPS 383.51(1),Wisc.Admin.
Code.Repair or replacement of failed or malfunctioning components shall comply with SPS 383,Wisc.Admin.Code.
No product for chemical or physical restoration of the POWTS may be used unless approved by the department in
accordance with SPS 384,Wisc.Admin.Code.
Contingencv Plan
In the event that any failed treatment component of this POWTS cannot be repaired,it shall be replaced pursuant to
a plan submitted to the appropriate agency for review and approval. A failed in-ground dispersal component may be
abandoned and replaced by a code-complying dispersal component in a pre-determined area of suitable soils.
Svstem Abandonment
If use of this POWTS is discontinued,it shall be abandoned in accordance with SPS 383.33,Wisc.Admin.Code.
Fteal Estate Sawyer County Property Property Status: Current
Listing
Today's Date: 6/6/2022 Created On: 2/6/2007 7:55:25 AM
Description Updated: 6/14/2017 Ownership Updated: 10/10/2019
_ _ _.
_ _ _ _
Tax ID: 14504 JAMES & MARCIA FRANKLIN PARK IL
P�N: 57-012-2-39-07-02-2 03-000- SUCHY REVOC
000080 TRUST
Legacy PIN: 012739022308
Map ID: .7.8 Billing Address: Mailing Acldress:
Municipality: (012) TOWN OF HUNTER JAMES & MARCIA JAMES & MARCIA
STR: 502 T39N R07W SUCHY REVOC SUCHY REVOC
Description: PRT SWNW TRUST TRUST
3022 ELDEN LN 3022 ELDEN LN
Recorded 2.150 FRANKLIN PARK IL FRANKLIN PARK IL
Acres: 60131 60131
Lottery 0
Claims: Site Address * indicates Private Road
First Dollar: Yes �OUN7Y HWY COUDERAY
Waterbody: Chippewa Flowage �� 54828
Zoning: (RR1) Residential/Recreational
One Property
ESN: 412 Assessment Updated: 9/26/2016
2022 Assessment Detail
Tax Districts Updated: 2/6/2007 Code Acres Land Imp.
1 State of Wisconsin G1-
57 Sawyer County RESIDENTIAL 2•150 209,100 45,100
012 Town of Hunter
572478 Hayward Community 2-Year 2021 2022 Chan e
School District Comparison g
001700 Technical College Land: 209,100 209,100 0.0%
improved: 45,100 45,100 0.0%
Recorded Totai: 254,200 254,200 0.0%
Documents Updated: l0/10/2019
_
WARRANTY DEED
Date Property History
Recorded: l0/2/2019 �` ' -
N/A
TRUSTEES DEED
Date
Recorded: 4/24/2001 -=----
i `� Q
-� f�e.w �errt�a,��h-� c.c�d�ess: �DSD� w Co -F}w� CG
Co� dera� � Lc� i .Sy gZ-g
p�. I —3lZ— yoU _ SZ�q
I �
Y� �., c � p '4 `. � �Pifi ;' ��r,,3,;t�,� bs ���q n�t�
c�� � ���.�» g�i � � ,�' r ff'�r��. �.s� � � ��9i
��R �' '!.I"'�q � �.: �i�'`y.:�. _ � � .7- I' t.i '..�a �t�'♦ r."h�'. �
� z � .. ;r - .�. �- TM ,e:� � �S )Yt,*�r-'�yi ';i
fYf� ;
{ '��` v�f� �, p �f ��y+' _ '� '.. Y � ,� Y� j�� �'. ;
� �7 �1- i3� y _ rr � r r..a° C nK � �� YR� ,.��91
�e �� ' � i � �_� rN �, ����_ ''°'ts�' '��� x' �` r��
E,�`� t s. � `� . i� ! �'�` �i.t
�s� �� '� k.�r � � ��� i ;�f.h, �, � f �', � t
�'. ` �a� � .'r "f,���'r�'' _.�', � '�.�f¢ ��:'';;
�� �,rh���� �_�./ �+� r ��- � i . :.�f1
��' �� i �v � ?'��`���>.. �r � .f�� ,l:
`y,�'��6'f:'. ,?'�y '�JS,.a�y s.y�.f�- ,.��� ��, f,�k � �"'�' ♦ � i l
���!`AS � '✓ {n,1 .-� � "�4,-�. I
; �,�--�'�:4,1�.. ��,f�.. f1 ,`5 •J �w�`... Nn ' �k. `'���/�
,ri '--� a �l��E�z,_.1y:�.�� �y '._ �i _ y�.-;,`�.
'PF y� � �,.T��t�'�y���A ..� ^��'�%k"'./���
� 7i� Y ,
'�'Yyt��f �t � � f '
.5�� �i�', -�
4�r,- > ! �i.�A
}�. x - �w. :�
.��> . f� J l� "� ` }., -"q�, . _
ai ,�[ •�- �',.,� ',;�o,�.
�+� �'
�� ,���` f,�,��/ R J Y � jK� '�w�8i� ":"�� ,��`�
� ;�L' �s.�ir "° 1 "� L �"_'-�' � �;
��`'• b� .p*�- v'; +�- �,�+'n � ' ■ _ '-i:
�i
�}�� '��� . ����.` �. . � - � �..
1 ��'�` .���. .�`3� :.J'.c � 1!��1`�: �
� ,r ,.
�� �'�-�, 1+`�., .�. 4 .:� ��l ,�'�
1 r. c x �+ .ev ttle ' � , F� '{a
'x`{, ���' � ,�',�'°� �" yr`���`
_� � z L� ~ ���i�����Z�� �T�v . �, � �a���, }�\�l
rj�.�.y4 � �? ��v� �; 1 � 1 <
{ . �`� '����}�:i� v � `�� _ � .� ti�+�i'.�
��� ���� �t�' H �5+.� 9 �o� � � , � � � ..
�y 1
..! � j'�-� 'r e'�*�%� � � tr'�� LIf[ 7� t��1
,�.`�` � ��,��.�-�r .,�`
�"` '� �>c � �� '�� E���t`',-fs� , � ,_ ''� ;��
����.1; �.,..���'Fryvf'-� r �r,'� r R �t r—N'c � �:�' ` j .�AS` 'S
��� ,r.� ��� ��� t�_� ��r �'9x j������������1
s����x4,j_ '/.� 1 '*' l ',�i � 3ila. r Y i'+���51��
j��^� � t.�.. '�4� . �:. .��y ji� }�wtiTR�,�
� �`A 11 { Fl1 '1!'� r��� }'�' `� �; '.� �.F11 �\� _
r �;��,�� `_` `� ��'r '��:, -dI a�- l�.e r 9� �;' `y,� _
r'��'"f S� ..;, ` �,�.#�f ' a;st � '«'a�`���t '4+[��, ��''�s?iY1{ _
z 7�: i -- / "g'' .�r �4i '
-•' i� ��. � , '-�� - �g.��r�' ..4 �r��f� f ' sk ■��,}��� � `..
4�' ��,��k t�.r ,a'�r 9 i������ s6r.+'�' �`,� ���,X f �`;r.+�s�6"Ti�
'�, � P' , ��°' � �; y, .,
t�Y.; ��Ls� �. �t�F���,�F�� ��� �� � ��.., .�` « ;�',
`i 1
e.-_�� f � � � 4.� 'Ir ��#J � `.,
r.. � �i �� ... y� �� _ �;.� X" ;./ {�. ,....x���'�,�
�i� ,''� S l',�r aMp _ ' :c` r �'".x�' ,�A= -"�. �a
�
,��f x � ,���tx, �,�� �Y9 1 '+�'�.�,��,� ti t��, , 3
Y `�'"s`l���} -'�i+ .�`. nr. "s't' xYP � ���`�`7������1�.
s ,y � � c.
� �� ,�5.'���.- .� _-__ F•� .k P � ..� �p 4r
� ` _� ��ai.._. �...n�'4 J �c,�'���'`i
J �� T{� I �� �� ""4.y�y Y'�� �C��,/��'(�
1,y�Y ,*r �''.:_]8 �'� � ��_t�'�3
4
� �-..;.a.;s � , �. , �': �$
,� - - -
`'"''�'��'"-"'r.� PRIVATE ONSITE WASTE TREATMENT �ounty
��% -r
��� � �K� SYSTEMS
���' °$ '�` Saw er
; ��;
`����� ps ��'� ( POWTS) Y
\"'�"`/� INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION ��, � ���
Personal infonnation you provide may be used for secondary purposes[Privacy Iaw,s. 15.04(1)(m)]
Permit Holder's Name: ❑City ❑ Vil�age �Town of: State Plan Transaction ID#:
J-M�2S �-V��a('c;a s��� 1Qe,v_T r.s ��K�i- '_
Insp BM Elev: BM Descrip ion: Parcel Tax No:
I r
p0 .D � a`"C' �- D�� -73`j^ O� - ���
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic �,,,;�� ,Jpo p Benchmark (�,ap,or
Dosing
Aeration Bldg. Sewer ��c'�`
Holding St/Ht Inlet ci5- Y �
TANK SETBACK INFORMATION St/Ht 0utlet .� '
TANK TO P/L WELL BLDG VENT TO ROAD Dt Inlet
AIR INTAKE
Septic �' �2 ' ' .}-6 ' NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man. q7�t�'
Holding Dist. Pipe
PUMP 1 SIPHON INFORMATION Infiltrative �� �
Surface
Manufacturer Demand Final Grade
Modei Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist. To Well
DISPERSAL CELL INFORMATION
DIMENSIONS �N ,3 L?� -� � #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav 1� Conv ❑ Aggregate
INFORMATION P/L Bldg Well Waters � IGP o Chamber
❑ AG m� EZFIow Model Number:
CELL TO p � .�-�s�� ❑ Mound o Other
-__ - - -- — - _—
- ---- -- - __
DISTRIBUTION SYSTEM X Pressure Systems Only
-- _ __ _ _— — ---- -----
Header I Manifold Distnbution Pipe(s) � X Hole Size X Hole Observation Pipes�
Length_ Dia Length Dia Spac L Spacing ❑Yes ❑ No
-------
SOIL COVER
-- - --- -- - -- —
De th Over De th Over ! De th of Seeded(Sodded Mulched
P p P
Cell Center Cell Edges I Topsoil _ _ ❑ Yes ❑ No ❑Yes ❑ Nc 1
COMMENTS: (Include code discrepancies, persons present, etc.)
���►r(,� : �- , j��s��-3
.s�rs = � 1► Y ��-3
Plan revision required?❑Yes ❑ No p� �� �Y � � —� �� ��
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3101)
A�OITIONAL COMMENTS ANO SKETCH
SANITAAY PERMIT NUMBEA.___��__
�.—G�,,� ,�to w �
. .
3�� � �
� ; _ . _ . , _ _ __; ' __
,___ , -�- -.�_ _ ..--
: �
;
, ; . , � ;.__ . ; _ _ __ .
� �b � _.+
. �S� �.. —j— ���c'� � .
_ �\�a � � ' � �� �
i —� ► --� �
�� � �
� �(��
����. i � - I
i
� i � � �
�c�d��` _` �
� ��
� �
I a�
� ,��5' �,�,C..
.
I �� r
����� '
I
�
�
-�— �o�b� . ���. ��
-r CJ
D
cre�=