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Home My WebLink About026-939-22-5712-SAN-2022-196 �,�`s�""`�� Department of Safety �°�'� �_ � � �� r, ;K & Professional Services, ` � Sanitary Permit Number(to be filled in by C .�� Industry Services Division �3� � �� '°�,d� g.-� Sanitary Permit Application StateTransactionNumber � _ � In accordance with SPS 383.21(2),Wis.Adm.Code,submission ofthis foan to the appropriate govemmental 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 ad� � the Depaztrnent of Safety and Professional Services.Personal information you provide may be used for secondary �� j_ `� � pu:poses in accordance with the Privacy Law,s. 15.04(1)(m),Stats. �`� �-.� .�:��6 '��``�� `' „i::� ,4�x?-.x. ��>t Property Owner's Name Pazcel# M i GG � G t^I, G�(r��t 3C1, ��.Z��(Z Property Owner's Mailing Address Property L.ocation �z yo 3 �5��. /{v�.. Govt.Lot 7 City,State Zip Code Phone Number ��j''f N �.."�,l`� ,�S'`/�y '/., I/., Section 2,Z. �r��„ ... ..,�. _. , __. .s.. . '�"�� ,_+,�r��». ..�. ""` � Lot# T 3�� N R Eor '� ❑1 or 2 Family Dwelling—Number of Bedrooms - Subdivision Name Block# ❑Public/Commercial—Describe Use ❑City of ❑State Owned—Describe Use CSM Number ❑Village of �7-Town of ��-tic� Lc�.�'� III.T�*.peuf:PE�V'�I'ermit:'{Ghinek:eitltec��lex?'os�'Repmc6menY';andot�i�r'ap�Sl�eablenri:liaeA. �h�ekaa+e:��et��-C• a� �iica[sle. ' : «_. � , � I ^ . _ �New System LJ Replacement System LI Other ModificaUon to Existing System(explain) C Additional Pretreatment Unit(explain) B' Holdin Tank ❑ In-Ground ❑ At-Cnade ❑ Mound ❑Individual Site Desi g gn ❑Other Type(explain) (conventional) C• ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑ Transfer to New Owner ist Previous Petmit Number and Date Issued Expiration �D(3—037 2 p�� ?(�O -�0 Design Flow(gpd) Design Soil Application Rate(gpd/s� Dispersal Area Required(s� Dispasal Area Proposcd(s� System Elevation �(��'l , Capacity in Total #of Maaufacturer Tank Information Gallons Gallons Units � � o 'g .� New Tanks Existiag Taaks � Q y � � ` � � V v� � v� � C7 G. Scptic or Holding Tank ��— ^ , 2,c�sc-v f Lu��P r' Dosing Chamber ., �� ww. . ,,.v.,. .,.,.er . . '� '� .;..2' .f��..'..:.. � ..�.......�...,�, ..; �. . ..: �. ... .��.:: .��2 - ' �.:'.:. s�s�.v. i�rf 't::.Y�:'�:. �':> . . ...�. . �. ., _ � .� 4 M _.. � � ,�-, � �:..��-. � '-�, , . . ... ,,... . . . .. ..: � ..; ..,. ,. ,. . .. . � ... . �.... . � �-. . . r ,r.s,.. . � .. . .:.. . ... .. . ... . , .. . Plumber's Name(Print) Plumbe 's Signature MP/'viPRS Number Business Phone Number Jerry Ruid Excavating, LLC Q_� z�-�y� � 7i,� _ �.4�,_yy�,j Pl i , , ip Code) Stone Lake,WI 54876 . . . , , . n-��-� � '��.� `�� a_ _��:..� �� _ =�:� : .� .. , -._ . . . .� e......e .._ .. ... .h_. ..:.i . . �., w.:.. •,.v .q . � . . . �A e ❑Disapproved Permit Fee Date Issued Issuing Agent Signahue �� $ ]�/ �'7�'�/ ❑Owner Given Reason for Denial -[0�'� �I� �'�a ��~�� Conditions of ApprovaUReasons for Disapproval r--: �a; �� , --� �.' r1''`+�� " �l; ��r11!`' 1 D ate��aa , �� 1��:��.� L` ��`-�%� � � �� I I N 3�� __. _. � � � � � . chk�� AU� 0 8 2Q22� CS� �� Rcpt# N�!d �8�f1 �— �2 � �—) q �,l1itiY�� < ..Oi1�d i`Y l/ �� ZONIN�ADP11fi�15TRATIUN Attac6 to complete plans for the syetem ead sabmit to the County only on paper not less ffian 8 1!2 z 11 inches in size NO Rc�FJNDS AFTEA SBD-6398(R.03/22) ISSUE OF PE'�cMIT ��''�(o S Sawyer County Zoning & Conservation Administration �� . 10610 Main Street, Suite 49 � ,�� -. 1� Hayward, Wisconsin 54843 � . �: �• , � " �,,,,,,�� % (715)634 8288 � �'�� , � FAX (715)638 3277 � p� i ,-i L � i�., � Ap'bb_A5 � bi\C COli�11�,�0�_.S�I� � � ...� >- J / E-17731� �Ori1s7� ti�C�I i:i14��7L1�L711i -�4\ f3I£: " � � Toll Free Courthouse/General Informat�on 1 877-699-4110 �� , � I�,; ,. --`� 1 ��"``� Holding Tank Approval Checklist I. Sanitary Cover Sheet Date Stamp � $ / o� / �� Parcel ID# D a �O -`� 3 `� _ �� _ S '-7 l .� II. Plot Plan � Property Lines ;>( Benchmark BM ♦ x Site Address � North Arrow � 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 Agreement form IV. Holding Tank Specifications Cross-section - Manufacture, Gallons: w'e-3'� ��`�°� 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 I�, SBD-10855-P (R.3/07)„ , �. 1 Owner: I�V� cG� � � Plumber: 'S. �� Application Review Date: �$(�� ,--.� POWTS Reviewer: ��.;... ln.�.��'c%�— Namc 6� 5� ( � Lsoonsc# Revised 4/11/2013 PAGE 1 OF 4 Holding Tank Plan Index & Cover Sheet Component Manua/Design Refe�ences: Version'i�D,SBD-10855-P(N.03/07;R 01/12),, /� Pg 1 of 4 a�� Index&Cover Sheet Pg 2 of 4 Plot Plan Pg 3 of 4 Hoiding 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 Owner Name(s): m ��;.G� ( 11to��l( Phone: - OwnerAddresa:Zuo3`iS"�Av�.N (3��rlywl�l� h1w Zip: SS��f�f�( ProjectAddress: ��F'��v 12�(n �a L„� s�o,�,e�l-4�C� s��F-7� � Govt.Lot: 7 1/4 of 1/4,Section 2 Z ,T 3`i N-R � E�or W Q Townahip: sLr�� -y.l'.�- County: Project Parcel ID#: � Z 6� '��'� z�'7�Z- Designer Information Jerry Ruid Excavattng,LLC 7i5 _`��a, 2��t Designer Name: Phone: Designer Address: Stone Lke,W��a876 Zip: S`{8 ?6 E-11181�� J C V le�(� G�•.��vrY i�1 •�G� 7iiis space recerved for approvxl stamp. Licenae Number. �--`{�-��2 Remarks: . Signature: � . ��-�i Date: � � ' ZL - -�� "qinal signature required on each su6mitted copy. � � N ,, , 1 , Ho r--�, Q 3.ri �{G S � 1� •�. D� V�.('S�0.�.1 Z. � 1 (>�•SS=-F��- �P� . �''�v7 , 2�0 �Satlav w,u�r � I t1c4�iw�� l >.v�L � . .4 � URP io� o� Ca.�� 3�;1d �.�� , 2. � 1 rn.K s ��-e. , �c� v (�q�� Habitable l-�ving �re2 shall nat bA �reated iC� a�ce�sorY S�ructureG> ; Fkdd��r�'v,� � I (� _ _ 1 _ _ " U . � � /v O 8� /�/ /\p K�i ri/ �iv Jerry Ruid Excavating, LLC ,z� 3� � � W /11,��e� i q� c�;�� W208 County HWY A �m�� /�; � - zyo3 SS.�a ,�ve. �/ Stone Lake,W� �876 /G�, � /3r�c.�: �y� 1 o�rK ��(,v z<<z`i� Z .�- s�yyy n"�'�� z�/z36 �t3o �^�� PAGE30F4 HOLDING TANK SPECIFICaTIONS (No Scale) wssa,a�roor �r nrw.a zo n wore Jwctlon and qPpmved ��F�°°d Elevatb" Alartn Box VaM Gp (��) S�8 and NEC�0� 4�a�j0 R hom � ��(�typicel) �� 4'Min.w 20}t abow Bu��9 1 Etlab9ehed=Flood EbveSon f AUtlflM Setl . . Ffiislbd fireds 18'A4n. . nYP�m) . '':. , Y . �. ' . . . • ,.. . .. a • . Inlet I�det Im�rt � yy�yOM Appiovsd.lohfbMAtli , . � APP��W 3 R anto Ma.1Y or 90%of�i vduma SoBd O�dad ' if mms than a�e mnk e � Alartn�On . : i HOLDING TANK VOLUME = z�� gal ', . e . • , . . . . � _ g•ppprpv�d Beddln0 MeOerW 89rbath TaN� TANK MANUFACTURER: w��5er" Anchor tank as necessary pursuant to SPS 383.43(8)(g) Bailast Weight= [(cu.ft.tank.vol x 62.4 Ibs/cu.ft)-Ibs.�nkwt]x 1 S Bailast WeigM= I( �2 ? cu.R x 62.41bs1cu.ft)- 79�" Ibs]x 1.5= Iz,ocx> � PAGE40F4 Holding Tank Management Plan IMPORTANT: The owner of this holding tank(s)shall be responsibie for its perpetual operation and maintenance pursuant to requirements of SPS 382-384,Wisc.Admin. Code. PursuaM to SPS 383.52(2j,Wisc.Admin. Code,this holding tank(s) shell be considered a human health hazard ff not maintained in accordance with this approved managernent plan. Furthertnore,all inspecUon and maiMenance activities shall be performed by a registered POVNi'S Ma(ntainer in accordance with SPS 383.52(3),Wisc. Admin. Code. Estimated Daily Wastewater Flow= i�0 gpd InsoeeUon Checklist INSPECT EVERY 3 YEARS o typB of u38 o age of system o nuisance faccors(i.e. odors, user complaiMs, 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., e�cceeding design capacities, prohibited activities, etc.) o electrical cornponents(i.e.,wiring, connections, switches, controls,timers, alarms, etc.) o suAace discharge of etfluent or sewage back-up into strudure served SERVICING FREQUENCY o The tank(s)shalf be pumped by a certfied septage servicing operetor Iicensed under s. 281.48 Wisc. Stats. when the wastewater in the tank(s) reaches a level of one foot below the inlet inveR of tha tank(s). Disposal of contents shall be pursuaM to NR 113,Wisc.Admin. Code. Tank pumping reports ahall be submiffed to the proper loeal govemmant unit in aecordance with SPS 383.55 Wis. Admin. Code. RepoR any eomponent failure or malfunction to: Nameofindividualorcompany: SGo7T'S SGp'r� G Phone: 7�5-�4`�' 7��R Lxal govemment urrit S�w y er' Co . 2 v•,., r.�..,o� Phone: �7/S' C�`{' $�� Localgovemmentunitaddress: �(3fo�O Vn0.�n� Sa Sv�t'P� �� 3"�0.y4b1`aZIP: sti $�(3 Any defective part of this system shall be 2paired, 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 tor chemical or physical restoration of the POWTS may be used unless epproved by the department in accordance wRh SPS 3&4,Wisc.Admin. Code. Corrtinaencv Plan In the event that any faiied 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. HOLDING TANK SERVICIIHG CONTRACT Coa�act Dabe: � /�/ '�� 'lbie oontnct b made between the Holdtng Tank Owner and the Pnmper. Holding Tank Owner's Nmme: Pumper's Name: M�c�.t�-rr� ��n.�.7e 1��-�� 5�..=:Y(-5 s�"<< c� Parcel Idmt�tion Nnmber: (12 Digit Legacy ID) I�2 � _ `Z 3 �- Z Z - `� —1 l Z 1. The owner agrees to fle a copy of this coatcact with t3�e govemmeatal imik Saa'Y��Y, which Las aocepted and n�with the Office of the Regisxr of Dada,the Maintenmce Ag�rxment for a Holding Tank nquired under the Sawyer Coimty Private Sewage Syatem Ordinence for the issoance af a Sanitary Pecmit for the installadon of a holding tank(s). 2. The owner agreea to have the holding ffinlc(s)serviced by the pimmper and guaisatas to permit tlte pu�er bo haYe eccess and to eabc upon the property for the piapoee of xcvicing the holding tmlds). Tbe owner agrees to mainisin the all-weather ecceas road or drive so thaz N�p�pa can savice the holding�s)avith the P�P�B�Pmmt• The ocvner fiuther agrees to pay�;ae pinnper for chargsa incimed in servicu:g the holding tnak(s; as �11Y a�'�d�bY tk;e owaer cnd pumper. 3. The p�per agrees to submit to t3te Govcn�l Uai;Sawyer Co�tY.a xeport for tl� servicing of the holding tanlc(s)as requued imde SPS 383.55,Wiscon�n Adminis�ative Code and the Sawyer Cou�y Privste Sewage System Ordinance. 1'he pumper fiather agcmea to include the following in the report: a The name and addisss of the pcaon�ble for seivicing the holding ta� b. The nmme of the owner of the holding tank; c. The ffibe addcssa of the hold'mg mak; d T7u date the holding tank was secvixd; e. The whmmes in gallons of the contmb p�ped fiom the hold'mg tealc for each servicin� f. The dieposal sitea to which the conte�s from the holding tank were delivend. 4. Thia agrammt will remain in effect imtil the oavner or pum�per terminetes thia co�ract. In the eveat of a change m tLis coa�act,the owner agrxe to file a copy of aay cl�an�es w this service conuact oz a copy of a neav service contract with Sawyer Co�mty within ten(10) bvsiness days 8om the dsbe of change to this seavice contxact Owaer's Na�:(Ptint) Ownet's Si�anae:(oob cee owec dw��N� N1��-�t �t�-5�i o.N� ?1 c-Cvi �� Pumper's Na�e:(Print) Ptuc�er's Si�a �` `�r.-�� _> �-�: � :/�• � � P�aaner's Regishah�a Number: �� Rcv.03/26/13 �o� �a,��.Q�� ! ' � I IIII 'I . i �l, lllill � L I �y�r' 't'�o��lnJ �a�n�S � � � 1 � � � Document Number pocument Title + X :4�35��5 �40641 PAULA CHI�SER REGiSTER OF DEEDS SAWYER COUMTY, WI �S/09/2022 �$: 16 AM RECORQIIVG FEE 30.OU � �AGE�: � Recording Area Name and Return Address Sawyer County Zoning Dept. 10610 Main Street, Suite #49 Hayward, WI 54853 0�6 -a�l-- �� .s'�7 I � Parcel Identification Number (PIN) THIS P�G� IS P�RT OF THIS LEGAL DOCUNiENT - DO NflT RElYIOVE. This irformation must be completed by submitter: documen# title. name & return address. ard PIN (if required). Other information such as the grar,t:rg c!ause, !egal description, etc., may be placed on this first page ci the decument or may be placed on additional pages ef t'r,e document. WRDA Rev. 12/22?2010 -USE BLACK INK ONLY- POWTS MAINTENANCE AGREEMENT For Hold[ng Tanks Ovmer's Name(s)as shown on deed: L4�'C�i`►�i �YLl3`�i l�t'�-�_'M�5� �t 1-'��- S vi 4�� ►v `--C��— —'�'��'F�� P erce l I d e n t i fl c x U on Num w er. --7 �p�A e��C��j (12 Digtt Leget.y ID) � Z W -��- Z�- � 1 �Z � '�' Of/% ' DANIEL J � �''��y Legat Description oF Property: �,�t -SEE ATTACHED SHEET- � HINMAN � t� We aclmowledge that appiicatfon�being made for the instaAatlon of a hoiding taMc(s)on the ��'�I�191 O�'�� P�►�v des«;c�.ed on me atcacr,ed sn�. ��F�F WIS�` ►11\t`��r� Retum To:Sawysr County Zoning and Consarvation Administratlon 10610 Main St Sulte 49,Hayward,YY154843 As an inducemeM to the County of SaMyer to issue a sanitary permit for a holding tank on the above-described property,the owner is responsible for the operetion and maintenance of the holding tank,iocking device,alarm and axess,and agrees to confom�to ail applicabie requirements af SPS 383,Wis.Adm.Code relating to hoiding tank management,including the tolbwing: 1. The owner agrees to contract with a person who is licensed under Ch.NR 113,Wis.Adm.Code,exoept as provided by Sectlon 281.48(3)(d),Stats.,to have the holding tank properry serviced and to fiie a copy of the service oontract with the govemmerttal uni� The owner further agrees to file a copy of any changes to the service contract,or a copy of a new service contracf,with the govemmerital unit within ten(10)business days from the date of change to the service contract 2. The oamer agre�to contract with a person licensed under Ch.NR 113,Wis.Adm.Code,who shall submit pumping reports to the govemmentai unit in a�rdar��with SP5 383.55,Wis.Adm.Code,for the servicing af the holding tank. in the case of exemption under Section 281.48(3)(d),Stats.,the owner shall submit the report to the govemmental unit. The govemmentai unit may errter upon the properry to investigate the condition of the holding tank when pumping reports may indicate the holding tank is not being properly mairrtained. 3. If the owner fails to have the hold'mg tank properly serviced in response to orders issued by the govemmerrtal unit tn prevent or abate a human health hazard as described in Seation.254.59,Stats.,the govemmental unit may enter upon the property and service,or cause�e tank to be senriced. Pursuarrt to Section 145.20(4)Wis.Stats.,a govemmental unit may assess the owner of a private sewage system for oosts related to the pumping of a septic or hdding tank The charges will be assessed as prescribed by Section 66.0703,stats. The owner agrees to pay all charges and cost incurred by the govemmer�fai unit for inspection,pumping,hauting,or othenNise servicing and maiMaining the holding tank in such a manner as to prever�t or abate any hurr�an health hazard caused by the holding tank. 4. This ag�eement wiil remain in effect oniy urrtil the govemmental unit responsible for the regulation of private sewage systems cerdfi�that either a soii absorption system that compiies with SPS 383,Wis.Adm.Code,or a muniapal sewer serves the property.In add'�tion,this agreemerrt may be cancelled by execuUng and r�cordirg said certification with reference to this agreement in such manner which will permit the e�astence of the certification to be determined by reference to the property. 5. This agreement shall be binding upon the ovmer,the heirs of the ov►mer,and assignees of the owner.The owner shall submit the agreement to the register of dceds,and the agreement shali be rec:orded by the register of deeds in a manner which will permit the e�astence of the agreement to be determined by reference to the prope►ty where the holding tank is instalied. -On� one o�wner si �rsd- ACKNOWLEDGMENT er' 'gn ture:, State of: � � County of: SG�w� �-� Owner's Name(Print): Subscribed and swom to before me on this }��-�i Ac�ti$�'��`'��l.``" (D T h day of A u �c ,20 2 � Date:� ( �� Z=.Z. By(Owners►vame): �:� � ►�-�G G< < 1 � Notary Public Signature: ` Drafted by. .. Public Notary Name(Print): ba-�;Q1 �. H��nv►1u+'^ �(��, �, My commission expires on: ��,��¢ r�,�� Personal i�ortnatlon you provide may be used for secondary purposes[Privacy Law,§15.04(I)(m)l Rev.03/26113 Parcel I:That part of Government Lot Seven(7), Section Twenty-two(22),Township Thirty-nine(39) North,Range Nine(9)West,Town of Sand Lake,Sawyer County,Wisconsin, more particularly described as Lot Six(6}as recorded in Volume Twenty-six(2G)of Certified Survey Maps,page 236- �37,Survey No. 6930 as Document No. 327604. Parcel II: Together with a non-exclusive easement for ingress and egress as shown on Certified Survey Map referred to herein and as shown in Volume Twenty-seven(27)of Certified Survey Maps, page 203-204,Survey No.7090 as Document No. 332685. Real Estate Sawyer County Property Property Status: Current Listing Today's Date: 8/6/2022 Created On: 2/6/2007 7:55:48 AM •�` Description Updated: 9/14/2007 ' Ownership Updated: 6/1/2018 �Tax TCf: � � 28865 � � �� MICHAEL S MC GILL CABIN TRUST BROOKLYN PARK 57-026-�-39-09-22-5 05-007- AGREEMENT MN PIN� 000124 , Legacy PIN: 026939225712 Billing Address: Mailing Address: Map ID: :7. 12 MICHAEL S MC GILL CABIN MICHAEL S MC GILL CABIN Municipality: (026) TOWN OF SAND LAKE TRUST AGREEMENT TRUST AGREEMENT STR: S22 T39N R09W 2403 95TH AVE N 2403 95TH AVE N �escrip�iqn; PRT GaVT LC)T 7, LOT 5 CSM BROOKLYN PARK MN 55444 BROOKLYN PARK MN 55444 26/236 #6930 Recorded Acres: 1.510 � Site Address * indicates Private Road Lottery Claims: 0 6088N ROBIN LN STONE LAKE 54876 First Dollar: Yes Waterbody: Whitefish Lake "' ` Property Assessment Updated: 9/28/2017 Zoning: (RR1) Residential/Recreational One ESN: 423 2022 Assessment Detail Code Acres Land Imp. ,; G1-RESIDENTIAL 1.510 205,600 367,700 � Tax Districts Updated: 2/6/2007 1 State of Wisconsin 2-Year Comparison 2021 2022 Change 57 Sawyer County Land: 205,60Q 205,600 0.0% � 026 Town of Sand Lake Improved: 367,�aa 367,700 0.0% 572478 Hayward Community School District Total• 573,3(JO 573,30b 0.0% 001700 Technical College . �+; Recorded Documents Updated: 9/14/2007 ` Property History 0 WARRANTY DEED N/A � Date Recorded: 5/31/2018 412580 0 WARRANTY DEED Date Recorded: 6/29/2007 347400 , 0 CERTIFIED SURVEY MAP Date Recorded: l2/28/2004 327604 liliE?5:�j22.S.S3:h�yF.:Y�Ot:i1t�.�CjO':'.OiCjJ:`iCC:f"SSrElld52�.i'.!".:35�:; �;(':�r';%1, �l::i' `�v'� PagF.=. t caf '; f .��.k \ � a�W,4 �1e9��yY/•;fi f �w� � r � � �,��,�. ,�,�, ,� � �. .�� J_. ,. i �.:- ��,f~� , �,,r ' ' ` x<� r: 'r�'T£ �I<. ��P�� f'�'. \ ��i �'9� .� fi. � ��Q; �� !�-'' ...,.E* r_��v �';�� - �i � �. �n rl:, r �� ,`��'�� :�� ,�,. �I� a . r� �'-' '�`, �.. r�� x ..; ry '�� ,r� 1� � � �+�� L . 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' r �� . �� 4_ �. �: 't�a < v'�l�,d� *�-",� ��;��,r '� � f�'�' �' c t�'`u� `�� . •� /�: r ; �'��' ;;�=.-'"'"f?� PRIVATE ONSITE WASTE TREATMENT county ��o�S �'�' SYSTEMS SaWyer ��--$;��:�`' ( POWTS) ��=x�=-'��=��%' INSPECTION REPORT sanitary Permit No: Safety and Buildings Division (ATTACH TO PERMIT) GENERAL INFORMATION ��— ��o Personal infonnation you provide may be used for secondary purposes[Pdvacy Law,s.15.04(1)(m)� Permit Holder's Name: ❑City ❑ Village [�Town of: State Plan Transaction ID#: ►'�' 11G�'1°`e` V�LVI� �' ✓`�"l�l l�g � Insp BM Elev: BM Description: Parcel Tax No: do.c�' � Q�' �c. o�-� -�3�' _�.2 -.�7( TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV Septic �',� �p Benchmark �pp,p' Dosing Aeration Bidg. Sewer �,9� Holding St/Ht Inlet �7.6 ' TANK SETBACK INFORMATION St/Ht Outlet _ TANK TO P/L WELL BLDG vENuo ROAD Dt Inlet AIR INTAKE Septic ��5� �-U0� � �� -� � NA Dt Bottom Dosing NA Installation Contour Aeration NA Header/Man. Holding Dist. Pipe PUMP/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 Bidg Well Waters °� G � Chamber Model Number: ❑ EZFIow CELL TO ❑ Mound o Other -- -- - — ------ ---- - --- -- DISTRIBUTION SYSTEM X Pressure Systems Only -- --- - Header/Manifoid Distribution Pipe(s) TX Hole Size X Hole Observation Pipes Length Dia Length_ Dia Spac � _ ' Spacing ❑Yes ❑ No — ----_.__-- SOIL COVER fDepth Over Depth Over �Depth of Seeded!Sodded Mulched Celi Center �Cell Edges Topsoil_ _ � ❑Yes ❑ No � ❑Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.} ��s�� 3/a-� ��I� � y�5� Plan revision required?❑ Yes ❑ No � j � I I I � �o��a3 � __ —� �� (� Use other side for additional information Date POWTS Inspec or's Signature Certification Number SBD-6710(R.3/01) AOOITIONAL COMMENTS ANO SKETCH SANITARY PEFMIT NUMBEA____�2�__ �� `� �� 0 �c� �' � �_ 5,�"��" �� - - - "�Q"• y` i,. 13� �R�. l, C �'1S'/ ��C o� C P� �IP� vty� Q �� —�d— �b��,' s.a�f�---