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Home My WebLink About002-940-01-5208-SAN-2022-204 '' "' Indusiry Services Division County � 4822 Madison Yards Way Sawyer � :,�_ - Madison,WI 53705 Sanitary Permit Number(to be filled in by � � �� P.O.Box 7162 Madison,WI 53707-7162 � �j� � �� State Transaction Number � Sanitary Permit Application � In accordance with SPS 383.21(2),Wis.Adm.Code,submission ofthis form to the appropriate govemmental unit ~ � is required prior to obtaining a sanitary permi�Note:Application forms for state-0wned POWTS are submitted to Project Address(if different than mailing �- the Departrnent of Safety and Professional Services.Personal information you provide may be used for secondary 14683 W Point Dr purposes in accordance with the Privacy Law,s. 15.04(1}(m),Stats. I.Application Information-Please Print All Informafion Property Owner's Name Parcel# David Al(en Jones Trust 002940015208 Property Owner's Mailing Address Prope�Location 228 S Calle Grande � Go�vt.Lot 2 City,State Zip Code Phone Number Orange,Ca 92869 %,, '/<, Section 1 II.Type of Building(check sll that appiy) Lot# T 40 N R 9 E o �i or 2 Family Dwelling-Number of Bedrooms 2 � Subdivision Name Block# � ❑Public/Commercial-Describe Use ❑City of ❑State Owned-Describe Use CSM Number ❑Village of .` J�T Town of Bass Lake IIL Type of POWTS Permit:(Check either"New"or"ReplacemenY'and other appiicable on line A. Check one box on line B.Complete line C i a licable. `� ❑ New S stem y �Replacement System ❑Other Modification to Existing System(explain) ❑Additionai Pretreatment Unit(explain) B" �Holding Tank ❑ In-Ground ❑At-Grade ❑ Mound ❑ Individual Site Design ❑Other T ype(eacplain) (conventional) ❑Chan e of Plumber ist Previous Permit Number and Date Issued C• ❑Renewal Befo�e ❑ Revision g ❑ Transfer to New Owner Expiration LIV��nOwh � IV.DisperssU'Treatment Area and Tank Information: Design Flow(gpd) Design Soil Application Rate(gpd/s� Dispecsal Area Required(sf} Dispersal Area Proposed(st} System Elevation 6 c� /�i. rl, j /f j tf�` Capacity in Total ,#of Manufacturer Tank Infom�ation Gallons Gallons Units � o 'd � � New Tanks Exisdng Tarilcs � o � � � � � � a U ci� � �n w C7 Li. Septic or Holding Tank ]O60l1060 000 'afiltrator Dosing Chamber V.Responsibility Statement- I,the aadersigned,assume responsibility for installation of the POWTS s6own on the attached plans. Plumber's Name(Print) Plumber's Signafure MP/MPRS Number Business Phone Number GERAI.,D FROEMEL �� 950111 715-558-1138 Plumber's Address(Street,City,State,Zip Code) 13502W Frcemel Rd Hayward,Wl 54843 VI.County/Department Use Oniy �,Ap ro �d` ❑Disapproved Permit Fee Date lssued Issuing Agent Signature $ -�/�� /J� �t✓ ❑Owner Given Reason for Denial y0�.� � �I� �°� " '�'�^�i�-�.t��- Conditions of Approva easons for'Disapproval ��,S .,��.,,��=`�� ,�1 �J�� L 0.� i� f I� � � l��tG ��I a-,,,,,�.'�a _ � i � ii� � ��, '� .�: lc�� ch � A�l� 12 2Q�2 r,.; ft�l'011cl �k�q(�� C sl /`r�,� p�_4►�� : 1�e�` � ° `� ,`�� ' ��6v`�� u'�?�°t ��s;a�,��rr��t�,��Yi�r� Attach to complete plans for the system and submit to t6e County only on paper not kss ffian 8 1/2 a 11 inches in size SBD-6398(R.03/21) �'��3 Sawyer County Zoning & Conservation Administration �� 10610 Main Street,Suite 49 � �� ,�1� Hayward,Wisconsin 54843 �� .�� ° �� (715)634 8288 "� V � � FAX(715)638 3277 � �r�� „y/ � , �l f � ,.� �z:�y�� ,etit�crcoti iti ��-_�i� � � � i E mail �oa3,7 �c,�r��.,,i�n I � . �— i . _ �2 iccu�it� ol.��s � `� � 'i, � Toll Free Courthouse/General informatwn 1 877-699-4ll0 I�..�,, :�°� �� z..`� �1\�t� Holding Tank Approval Checklist L Sanitary Cover Sheet Date Stamp �g / �� / 2� Parcel ID# � b a-`� �( O -C� L-�,2 �`a II. Plot Plan �Property Lines D�Benchmark BM ♦ �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:C� �, �`� , �06D �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 �Versionp3,SBD-10855-P (R.3/07),_ , �,� Owner: �oY.z.s �r,,�.� Plumber: �"7 �� Application Review Date: �� a- �� c POWTS Reviewer: � � Name �`i �l lo �s��ns�a Revised 4/11/2013 PAGE 1 OF 4 Holding Tank Plan Index & Cover Sheet Component Manual Design References: Version 2.$, SBD-10855-P (N. 03/07; R 01/12) Pg 1 of 4 Index & Cover Sheet Pg 2 of 4 Plot Plan Pg 3 of 4 Holding Tank Specifications Pg 4 of 4 Management Plan Attachments: Enclosures: POWTS Application for Review Soil Evaluation Report & Site Map (if applicable} Holdin Tank Pum in Contract if a licable) Holdin Tank A reement if a licable Project Name / Description Owner Name(s): David Allen Jones Phone: - - Owner Address: 22$ S Calle Grande Orange,CA Z�p. 92869 Project Address: 14683W Point Dr Govt. Lot: 2 _ _1!4 of 1/4, Section � , T 40 N-R 9 E�or W� Township: Town of Bass Lake County: Sawyer Project Parcel ID#: 002940015208 Designer Information Designer Name: Gerald Froemel Phone• �71�) 558-1138 Designer Address: 13502W Froemel Rd Hayward,Wl Z�P: 5q.g43 E—mail: layfroemel@gmail.com T'his:pace reseived f��r ap��coval stamp. License Number: 950111 Remarks: Signature: G Date: $��0/22 Original signature required on each submitted copy. s� _ �:v� � , IJuv�� l'��e�r Sone3 �o�LoT`2, SPc.I�TYdnJ��4�✓ /I, ��0024yDo1 s�o� ��1 F;�� !ybfr3 w %owH o F�ss1��P I�.-.k S ,r`o 2`IobolhF,�r,ura�(�{T P.. ��'4 N�� ,,�s�``,�% 5��,0 �•� NF � (�m = <o�.��,mfs:�l..� ry6�b,Ql,.y Q�''i= l00,00' D" . aF{ww�� q2 0' � �— ��c.P �=� °�� r�� 0 N�//!f'`7roi�i PAGE 3 OF 4 HOLDING TANK SPECIFICATIONS (No Scale) Weafherpmot 12"Min.or 2A ft above Junctlon and q�ro�� Eshablished Flood Eleva6on Alarm Box (typical) Vent Cap ElecMral must complY N+� + Approved Loddng Manhole SPS 316 and NEC 300 4"0 Vent Pipe with Waming Label Attached CorMuit >70 ft irom (typira�) 4'Min.or 20 fl above Building � EslablisFied Fiood Elevation (tyPinl) - �AitlightSeal ° Flnlshed Grade 18"Min. ' (tYW�9 a 8 �� Inlet lnvert Watertight Appmved Joinfs with � _ �Max. 12'or 90%of total volume Plug � Approved Pipe 3 ft onto Solid Ground � ff moie than one tank a " Alarm-0n : HOLDING TANK � VOLUME = 2,000 9al a ' . d . . �a . � � . . 6 . 3'Approved Bedding Material BeneaUi Tank TANK MANUFACTURER: Infiltrator Anchor tank as necessary pursuant to SPS 383.43(8)(g) Ballast Weight= [(cu.ft.tank.vol x 62.4 Ibs/cu.ft)- Ibs.tank.w[]x 1.5 Holding Tank eMenor dimensions in inches: (Length "x Width "x Height ")/1728=0.00 ft3 Ballast Weight= [( 0.00 cu.ft. x 62.4 Ibs/cu.ft x 1.5) - Ibs = 0 �ys PAGE40F4 Holding Tank Management Plan IMPORTANT: The owner of this holding tank(s) 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 holding tank(s) shall be considered a human health hazard if not maintained in accordance with this approved management plan. Furthermore, all inspection and maintenance activities shall be performed by a regis#ered POWTS Maintainer in accordance with SPS 383.52 (3), Wisc. Admin. Code. Estimated Daily Wastewater Flow = 200 gpd Inspection Checkiist 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 activities, etc.) o electrical components (i.e., wiring, connections, switches, controls, timers, alarms, etc.) o surface discharge of effluent or sewage back-up into structure served SERVICING FREQUENCY o The tank(s) shall be pumped by a certified septage servicing operator licensed under s. 281 .48 Wisc. Stats. when the wastewater in the tank(s) reaches a level of one foot below the inlet invert of the tank(s). Disposal of contents shail be pursuant ta 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: Name of individual or company: Jays Septic Phone: �715) 558-1138 Local govemment unit: Sawyer County Zoning Phone: �715) 634-8288 Local government unit address: 10610 Main St, Ste 49 Hayward, WI Z�P: 54843 � � 8 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 faited 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. � � § � Continqencv P(an � In the event that any failed component of this holding tank(s) cannot be repaired, it shaN 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 SERVICING CONTRACT Contract Date: �/�/� This contract is made between the Holding Tank Owner and the Pumper. Holding Tank Owner's Name: Pumper's Name: ��'i� -�1fG.�tiJ B� .ScDr/`� S�I'�� Parcel Identification Number: (12 Digit Legacy ID) Q� 2 -��'1 �/ O - O J - ,�� O $ 1. The owner agrees to file a copy of this contract with the governmental unit, Sawyer County, which has accepted and recorded with the Office of the Register of Deeds,the Maintenance Agreement for a Holding Tank required under the Sawyer County Private Sewage System Ordinance for the issuance of a Sanitary Permit for the installation of a holding tank(s). 2. The owner agrees to have the holding tank(s)serviced by the pumper and guarantees to permit the pumper to have access and to enter upon the property for the purpose of servicing � the holding tank(s). The owner agrees to maintain the all-weather access road or drive so that the pumper can service the holding tank(s)with the pumping equipment. The owner further agrees to pay the pumper for charges incurred in servicing the holding tank(s)as mutually agreed upon by the owner and pumper. 3. The pumper agrees to submit to the Governmental Unit, Sawyer County, a report for the servicing of the holding tank(s)as required under SPS 383.55, Wisconsin Administrative Code and the Sawyer County Private Sewage System Ordinance. The pumper further agrees to include the following in the report: a. The name and address of the person responsible for servicing the holding tank; b. The name of the owner of the holding tank; c. The site address of the holding tank; d. The date the holding tank was serviced; e. The volumes in gallons of the contents pumped from the holding tank for each seroicing; f. The disposal sites to which the contents from the holding tank were delivered. 4. This agreement will remain in effect until the owner or pumper terminates this contract. In the event of a change in this contract,the owner agrces to file a copy of any changes to this service contract or a copy of a new service contract with Sawyer County within ten(10) business days from the date of change to thi �rvice contract. Owner's Name: (Print) OW 0T' S1gTlStlkT�: (Only one owner signature reqwred) lh.v'c. �. `P� �(lL�- cc��1,�5 � i '''. , � � Pumper's Name: (Print) Pumper's Signatu :� �S�n"�Po'p ./ Pumper's Registration Number: �f/�/ 3 Rev.03/26/13 i� �i ��ii i�►ii��fr�ii��i� so � z � a � -USE BLACK INK ONLY- i;�;��j�j;� POWTS MAINTENANCE AGREEMENT 44t�7�4 For Holdin Tanks PEIULA CHIS�E6t g REGIST�R OF DEEDS Owner's Name(s)as shown on deed: � SAWYER CC3UlYTY, WI i 08/22/2t322 ifl:l4 AM �ur� �, �'ov��Tn.,sfi RECORDI[�it'i FEE 3D.00 Parcel Identification Number: 'Q PA��. � (12 Digit Legacy ID) C� � � -� �Q - ��-�� U Legal Description of Property: -SEE ATTACHED SHEET - We acknowledge that application is being made for the installation of a holding tank(s)on the property described on the attached sheet. Return To:Sawyer County Zoning and Conservation Administration 10610 Main St.Suite 49,Hayward,WI 54843 As an inducement to the County of Sawyer to issue a sanitary permit for a holding tank on the above-described property,the owner is responsible for the operation and maintenance of the holding tank, locking device, alarm and access, and agrees to conform to all applicable requirements of SPS 383,Wis.Adm. Code relating to holding tank management, includfng the following: 1. The owner agrees to contract with a person who is licensed under Ch. NR 113,Wis.Adm. Code, except as provided by Section 281.48(3)(d), Stats.,to have the holding tank properly serviced and to file a copy of the service contract with the governmental unit. The owner further agrees to file a copy of any changes to the service contract, or a copy of a new service contract,with the governmental unit within ten (10)business days from the date of change to the service contract. 2. The owner agrees to contract with a person licensed under Ch. NR 113,Wis. Adm. Code,who shall submit pumping reports to the governmental unit in accordance with SPS 383.55,Wis.Adm. Code,for the servicing of the holding tank. In the case of exemption under Section 281.48(3)(d). Stats..the owner shall submit the report to the governmental unit. The governmental unit may enter upon the property to investigate the condition of the hoiding tank when pumping reports may indicate the holding tank is not being properly maintained. 3. If the owner fails to have the holding tank properiy serviced in response to orders issued by the governmental unit to prevent or abate a human health hazard as described in Section.254.59, Stats.,the governmental unit may enter upon the property and service, or cause the tank to be serviced. Pursuant to Section 145.20(4)Wis. Stats., a governmental unit may assess the owner of a private sewage system for costs related to the pumping of a septic or holding 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 governmentai unit for inspection, pumping, hauling,or otherwise servicing and maintaining the holding tank in such a manner as to prevent or abate any human health hazard caused by the holding tank. 4. This agreement will remain in effect only until the governmental unit responsible for the regulation of private sewage systems certifies that either a soil absorption system that complies with SPS 383,Wis.Adm. Code, or a municipal sewer serves the property. In addition,this agreement may be cancelled by executing and recording said certification with reference to this agreement in such manner which will permit the existence of the certification to be determined by reference to the property. 5. This agreement shali be binding upon the owner,the heirs of the owner, and assignees of the owner.The owner shali submit the agreement to the register of deeds,and the agreement shall be recorded by the register of deeds in a manner which will �,,permit the existence of the agreement to be determined by reference to the property where the holding tank is installed. r i ly one owner signature required- ACKNOWLEDGMENT O ne 's Si . State of: w �S��S�"� County of: �..�y�-� Owner's N� e rint): Subscribed and sworn to before me on this l � �� day of � N S� , 20 �-a Date: By(Owner's Name): _ 4 v� 4 I��,� So^e � ' � �� Notary Public Signature: "��""��.,,� Drafted by: C r��\ � Public Notary Name (Print)� �" `'�� •D�`-'• � ��'�,� '�� c w e"� My commission expires on: e�` `��_Q� �� 1�-,-�e�'� � NL�� .- �a-�-�`��'uJ j` � —•'�c, � z: v�� - �� - - Personal information you provide may be used for secondary purpose�[Privacy Law,§15.04(I)(m)] '�ev.'03/�/�g�' .•�,�� r ��%,�'T T•.......•\ G��. 5 .,��q„F"oF1,�`',``��. Grantor conveys to Grantee the following described real estate in Sawyer County, State of Wisconsin(if more space is needed, please attach addendum): Parcel I: That part of Government Lot Two(2),Section One(1),Township Forty(40) North,Range Nine(9)VVest,more particularly described as follows: Commencing at the center quarter corner,an iron stake,of Section One(1); thence running variation SO4°O1'E,a distance of 1,347.2 feet along the North and South quarter line to an iron stake; �hence running variation N85°59'E,a distance of 54l feet to an iron stake,the point of beginning; thence running variation N36°31'VV,a distance of 382 feet to an iron stake; thence running variation S53°29'W,a distance of 16b.45 feet to an iron stake; thence running variation S36°31'E,a distance of 482 feet to an iron stake; thence running variation S48°28'E,a distance of 163.5 feet to an iron stake on the shoreline of Spring Lake; thence running Northeasterly along the Shoreline of Spring Lake a distance af 100 feet to an iron stake; thence running variatioo,N24°49'W,a distance of 178 feet to an iron stake; thence running variation N36°31'W,a distance of 100 feet to the point of beginning, Together with a non-exclusive easement for ingress and egress by instrument recorded September 25, 1995 in Volume 562 of Record§,page 41. � � /� �� \�1�� y�J� �� ,. � I� \ � �Y , � Oftice of / f� � . � . Sawyer County Zoning Administration `'� ,- _ 10610 Main Strcet Suite 49 �'�'�; ��.�� Hayward, Wisconsin 54843 /.�� (�R Cp�� (715)G34-R288 f ��'�/ �Sl. ZI FAX (715)63R-3277 C� �� Q � .��j wti��v.sa�wcrcoun[v� ��o� q!i^ � % Vl� , -- j % E-mail: zoningsecrcusawVereottntveov.org UV � �� / o . -�� F= - ;, � Toll Frcc Courthousc/Gencral lnforma[ion I-877-699-4I10 � 2 � I _ S'Q(� E O �I�Z '� - " �c_- 2�N1, �Y � �� '�:oN;' vGq°M�n�i,°�'ti`r y T�ar,o;+v SAWYER COUNTY SANITATiON DEPARTMENT TEMPORARY EMERGENCY TANK INSTALLATION APPROVAL PROPERTY OWNERS NAME: D�lvi d�A �o�S �MS� TOWN OF: �u 55 � 1� ADDRESS: �- � �-( (,'g3 �I 'Yo1..'�' �`�,.�_ 1, ��'r*�+ �. � ��'`P6��/ , a Wisconsin Licensed Plumbcr, authorized by the owner, do hercby acknowlcdge that I am rcceiving temporary approval to install a septic tank/holding tank without a soil and site evaluation, or existing system evaluatiot�, and private sewage system plan review due to inclement weather and/or health and/or safety emergency. Further, I acknowledge that a soil and site evaluation, or existing system evaluation, and private sewage system pla►1 review will be conducted by the deadline stipulated by the permit issuing agent, or as soon as weather conditions or circumstances permit. Tf the private scwage system is found to be failing as de�ned in s. DSPS 381 .O1 (92), Wisc. Adm. Code, corrective measures will be takcn as such tl�at the pt-ivate sewage system complies with all applicable requirements of cl�apter DSPS. 383, Wis. Adm. Code, within 90 days of this agreement. I further acknowledgc that failure to comply by obtaining all necessaiy permits aftcr the deadline date may result in the issuing of a citation, under Section 1 L3 [2) Sa�iitary Pern�its], of the Sawyer Couuty Citation Ordinance. DEADLINE FOR THIS AGREEMENT SHALL BE: � �Y �a- � Signed: �-�� Datc: � �Y ( �Z Accepted by: ��. �„ Datc of temporary e�nergency approval: (��`� /2 � Rev. 03/26/13 8/4/22,3:59 PM Real Property Listing Page Redl EState Sawyer County Property Listing Property Status: Current Today's Date: 8/4/20Z2 Created On: 2/6/2007 7:55:06 AM �� Description Updated: 3/22/2016 -� Ownership Updated: 6/12/2017 Tax ID: 2683 DAVID ALLEN JONES TRUST ORANGE CA PIN: 57-002-2-40-09-01-5 05-002-000080 MARY L ZUPANC TRUST MILWAUKEE WI Legacy PIN: 002940015208 Map ID: :2.8 Billing Address: Mailing Address: Municipality: (002)TOWN OF BASS LAKE DAVID A JONES TRUST DAVID A JONES TRUST STR: SO1 T40N R09W 228 S CALLE GRANDE 228 S CALLE GRANDE Description: PRT GOVT LOT 2 ORANGE CA 92869 ORANGE CA 92869 Recorded Acres: 2.310 �: Calculated Acres: 2.265 `" Site Address * indicates Private Road Lottery Claims: 0 14683W POINT DR * HAYWARD 54843 First Dollar: Yes Waterbody: Spring Lake ' Property Assessment Updated: 6/12/2013 Zoning: (RR1) Residential/Recreational One 2022 Assessment Detail ESN: 406 Code Acres Land Imp. G1-RESIDENTIAL 2.310 110,000 21,400 " Tax Districts Updated: 2/6/2007 1 State of Wisconsin 2-Year Comparison 2021 2022 Change 57 Sawyer County Land: 110,000 110,000 0.0% 002 Town of Bass Lake Improved: 21,400 21,400 0.0% 572478 Hayward Community School District Total: 131,400 131,400 0.0% 001700 Technical College Recorded Documents Updated: 6/24/2013 � property History QUIT CLAIM DEED N/q Date Recorded: 1/23/2013 383129 WARRANTY DEED Date Recorded: 10/12/2004 325740 WARRANTY DEED Date Recorded: 7/9/1984 191976 364/224 https://tas.sawyercountygov.org/system/frames.asp?uname=Eric+Wellauer 1/1 -��'t-`-�'"='-'��`�>; PRIVATE ONSITE WASTE TREATMENT co�nty ��,� 7� � o �' SYSTEMS Sawyer �- $p �;�� :S. �� ` ,�. ( POWTS) �R�;_—��`� �'�°��=��" INSPECTION REPORT Sanitary Permit No: Safety and Buildings Division (ATTACH TO PERMIT) GENERAL INFORMATION �� - �O � Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(I)(m)] Permit Holder's Name: ❑City ❑ Village Town of: State Pian Transaction ID#: �,�. ,�1Q� So,.�.s s� �ss 1�1�— r-. Insp BM Elev: BM Description: Parcel Tax No: `CD.c.� ��' a �51�� n ��-�Ya_�l rS^o�g TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV Septic Benchmark ��,o' Dosing Aeration Bldg. Sewer �$.�'' Holding � - �'� �p(�p f �l Ht Inlet � �i$ •2S ANK SETBACK INFORMATION �t,/Ht Outlet ( �t 7.83 ' TANK TO P/L WELL BLDG vENr To ROAD �Inlet �}--�']' ,�v q�•7-f' AIRINTAKE Septic NA Dosing NA Installation Contour Aeration NA Header/Man. Holding t�s Sr--� ' 6 � `�—(, � �zS" � Dist. Pipe PUMP 151PHON INFORMATION Infiltrative Surface Manufacturer Demand Final Grade Model Number GPp,� p��,,,�.,,� Qa�S� 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 o Conv ❑ Aggregate INFORMATION P/L Bldg Well Waters °� GP ❑ Chamber Model Number: ❑ EZFIow CELL TO ❑ Mound o 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 0 Yes ❑ No -- — — -- --- SOIL COVER — -— -- Depth Over Depth Over '� Depth of Seeded/Sodded Mulched Cell Center 1 Cell Edges Topsoil _ __ � ❑Yes � No ❑Yes ❑ No COMMENTS: (Include code discrepancies,persons present,etc.) ��i� �1�� a--� �T Plan revision required?0 Yes ❑ No I � '03,�� a3 � J� l� � �,.�� --� Use other side for additional information Date POWTS Inspector's Signature Certification Number SBD-6710(R.3/01) A�OITIONAL COMMENTS AN��S7K,,,ETCH SANITAFY PERMIT Nt1M9EA�._____�"�_=e�:.� . . N ��P�"�� t %)` �, i� ��. +�.5 6 c�.b�� l�-�� ` ,, , (�,"�"' *a �uo B� � �j� � S>� � S d�� --- �``�6� �,�— -� Pe.��