HomeMy WebLinkAbout032-539-27-4305-SAN-2022-206 �
Department of Safety c°°°ty �
� & Professional Services, �
S _ Sanitary Pen it Number(to be filled in by Co.)
P= _ Industry Services Division 4J
(fJ �J�� ����' VJ
�
Sanitary Permit Application State Ttansaction Nu=ber �
[n accordance with SPS 383.21(2),Wis.Adm.Code,submission ofthis fortn to the appropriate govemmental unit �
is required prior to obtaining a sanitary permit.Note:Application forms for state-owned POWTS are submitted to Project Address(if diffcrcnt than mailing addre
the Department of Safety and Pmfessional Services.Personal infortnation you provide may be used for secondary �$23vy Lqke Wi rrF er Rd
purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats.
I.Application Information-Piease Print All Ioformation WIY�'+e j rj
Property Owncr's Name Pazccl#
Q�� Q 32S 3 • O
Property Owner's Mailing Address Property Location
fQ e Q Govt.Lot
City,S[ate Zip Code Phone Number
�v '/.,�_�'/<, Section�._
Co ' 80 5 470 4 0-
❑.Type of Building(check all that apply) I.ot# T N R E o
�1 or 2 Family Dwelling-Number ofBedrooms � Z Subdivision Name
Block#
❑Public/Commercial-Describe Use
�City of
❑State Owneci-Describe Use CSM Number ❑Village of
1y,�3'74 *�3`t'1 �To,�,ot�(infe►�
III.Type of POW'I'S Permit:(Check either"New"or KReplacement"and other applicable on line A. Check one box on line B.Complete line C if
a licable.
A.
�New System ❑ Replacement System ❑ Other Modification to Existing System(explain) i� Additiona]Pretreatment Unit(explain)
B' ❑ Holding Tank ❑ In-Ground ❑At-Grade gn ( p )
❑ Mound ❑ Individual Site Desi Other T e ex lain
(conventional) �C�•/"'��►�na �"'� �f
C. ❑ Renewal Before ❑ Revision � Change o(Plumber �Transfer to New Owner
����c 3�rmit Number and Date Issued
E xpiration ,� L Z^ /7 �Z
IV.DispersaUTreatment Area and Tank Information: �q r ! =2$ O r Vp
Design Flow(gpd) Design Soil Application Rate(gpel/s� Dispersal Area Required(st Dispersal Area Proposed(sfl System Elevation
HSo .Z.b .�l G�43 L6 z$2 uS ���� 9y.65'
Capacity in Total #of Manufactu er
Gallons Gallons Units v o 'n �
Tank Information � ,. U ;; �
New Tanks Existing Tauks � o ¢� � y p � �
a U � � v� i+. C7 0�
Septic or Holding Tank � D� � �/��� � �e g!� x
Dosiug Chamber
V.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans.
Plumbcr's Name(Print) Plumber's Signa r MP/MPRS Number Business Phone Number
22 1 � 4�.3 ? t'
Plumbcr's Address(Street,City,State,Zip Code)
ION OI lt � 8 S
Vl.County/Department Use Only
�A}� ❑Disapproved Permit Fee Date Issued Issuing�jgent Signature
/� / $ � �j � I /'� ll'IJU'.1-
`V"`� ❑Owner Given Reason for Denial ��. ��7 .��
Conditions of Approval/Reasons for Disapproval , �
r ►� � ���
. � � i� � ��
���._� �. �_._ _
�'r '� r cnk# ��� � �
��
�C,ST `�,_�t�!`�.��� � 3c�� AUG 16 2022
a-a - � 3 S� --�-
SAWYER COUNA ION
Attach to complete plans for the system and submit to the County ooly on paper not less Man S t2 z 11 io ea n size
SBD-6398(R.03/22) NO REFUNDS AFTER
I�SUE OF PERMtT -�S�-{�,y
GeoMat IN GROUND AND PRESSURE DISTRIBUTION COMPONENT DESIGN
INDEX AND TITLE PAGE
Owner Info
Project Name: Dennis Renley
Owner's Name: Dennis Renley
Owner's Address: 1601 N College Ave
Fort Coliins, CO 80524
q70 g►gp 37't 3
Property Info
Property Address: 5823W Lake Winter Rd
Winter, WI 54896
Legal Description: SW NE S 27 T 39 N R 5 W
Township Winter County: Sawyer
Subdivision Name: CSM# 14/376 #3617
Lot Number 2 Block Number CSM#:
Parcel I.D. Number. 32539274305
Plan Transaction No.:
Index Pages
Page 1 Index and Title Page 7 and 8 ��R Nl��l� ERtT PL�N
Page 2 Plot Plan
Page 3 Sizing Information
Page 4 and S Inground Plan View
Page 6 lateral Layout
License Number: �,,Z�g{
Date: 07/29/22 Phone Number: R�r� g�� � g
,
Signature:
Designer Stam . State of Wisconsin Approval Stamp:
Designed Pursuarrt to the
GeoMat In Ground Component Manual Ver. � ��,�,�� � �, �q
GeoMat In Ground Version 1.0 (R. 3/20/17)
. r
SITE PLAN ELEVATIONS �
DENNIS RENLEY BM=100.0',NPJL IN 14"DIA.BALSAM TREE
5823W LAKE WINTER RD
�1=98.5'
SW,SE,S27,T39N,R5W g_p=gg,��
TOWN OF WINTER g.3-gg.0'
8-4=99.35'
DESIGN WASTEWATER FLOW=450 GPD
SYSTEM EL.=94.65'
--SEE SIZING INFORMATION SHEET
LATERAL EL.=95.8'
APPROXIMATE SURFACE EL.WHERE
� BUILDING
SEWER DGTS HOUSE=96.55'
LAKE WINTER RD
N #5823
SCALE:'I"=40'
� I
DR.WAY
#224281
q$F� �
�� 99.35•
❑
�CS '
. - ❑ B-1
� 98.5'
� �
�
� PROPOSED
� SYSTEM
i
� BM
` &2 ❑
98.1'
i �
❑
� \63
98.0'
PROPOSED
HOUSE
LAKE WINTfiR 86.0'
GEO MAT LEACHING SYSTEM DESIGN -GRAVITY SYSTEM
OWNER- DENNIS RENLEY
1. DWF =450 GALLONS.
2. BASAL AREA REQUIRED-AN IN SITU SOIL LOADING RATE OF 1.6 GPD/ SQ. FT. SHALL BE USED.
450 GPD / 1.6 GPD PER SQ. FT. =28125 SQ. FT.
3. LOADING RATE FOR GEOMAT=2.0 GPD/SQ. FT.
GEO MAT REQUIRED =450 GPD-2.0 GPD/ SQ. FT. = 225 SQ. FT.
225 SQ. FT-(GEO MAT WIDTH) 3.25 FT. =6923 FT REQUIRED (2 - 35 FT. CELLS)
4. BASALAREA AVAILABLE.
35 FT. X (6.5' + 125+ 125' + 1') =350 SQ. FT.
ABSORPTION AREA= 10 FT. X 37 FT.
5. ELEVATIONS.
SYSTEM EL. = 94.65 FT.
LATERAL EL. = 94.65 FT. + 1.16 FT. = 95.8'
SYSTEM WILL BE DESIGNED FOR GRAVITY FLOW. SEPTIC TANK OUTLET= 95.8 FT. + .66 FT PITCH
= 96.45 FT. OWNER WILL PROVIDE SUFFICIENT COVER MATERIAL OVER BUILDING SEWER.
in Ground Plan View
i �L' �i� =~
R �S�
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..`��'..�'�-:i C� :;,J : - G G,G Q_7�Or,O C C�J G_�3r�,� �_:��C^' � �_ .� . OC�.GOlO C3a7_� �..��
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�� G�O '� J O`��*�._p -� • r_p-. -:� C,v �_ �'� O G G O'..?`�Q-� O O'C'"O O`�� 9 O"O 7=G u n C„O_p Q ,' �
__:�Lv��,?__�_G�v C?_.r._Gr,:����;;G �i C}�?-G v G_::G c7�C•J_Cr'v G O� G J O � O �v O U`G v il G'O �_v Q
'_v�..O • � • �„v 1,;J J C J �; O C��.: J J„J .l ,1 t.• r � O O G O O j v O -, r. .'� G_.; C G O r�
1 j�v .. �i��t:`v Ci :.�_J O Q G J .� �n �� �_J ^--• . � n -,- -.
=^� .� n � . - .-i �-%r=n .:.'� r';� n n.� .n n , c-��1�7�r-�'n✓ _ O CiO 01c7 C��^-'C•�n��ne�CnC qf�•
'- --------- n n
�' � � � �5' l
,_ ,
,
�7'
tn Ground Componerrt Dimensions
3.25 A (ft) �S6 - Basal Mea Available (fl)
��# B (ft) 28125 Basai Are�a Required (ft�)
� �►`- L (ft) Observairon Pipes P}aced @ End of C�oMat
� : W (ft) 225.00 Requir�d Dispersai Ceii Basal Area (9Pd/ft�)
1.00 S (ftj ��74.5" Proposed Dispersal Celi Basat Area (9Pd�f�)
,�t� Side Dimension (i) (ft) .�-1�'• Linear Loading Rate (9Pd/ft)
1.00 End Dimension (tq (ft)
3.13 L�pth of Cover (in)
In Ground Cross Seciion View
GeoMat Dispersai Area
99 ft--► Finished Grade \�i V' `� �k��t" Y ��E'�l`�,Y
1 � �,:�*�rr_,'�::
3_13ft - � �3:���:��ii Ir^�`�1�,��1
^-- ^/�.�-�<.�+r.��<,: 12"-42
V���!7 W �.i!' " I . -
� :"� �` ��.:�y
�� lr1--� L'zjf Tss:. Dist -. .
- ' - Pi{x `` Y rE:.:_.
Top of geomat to be at or " - - ' � � •,��-.�-�-
• T/�
:a:_j-�.� s-'�-�``-L= � r- � `.:i Y.,'��..�.�
�IOW Oflgl(1�� �f'd� " s , ' . . , . � : c + f-.�.�`"' ..S
, F •�_•�r;,`'
94.65ft ! : � I � , l ; ��"��Z'�'� �� L� � � � ' � '• ; I� q ^..�
—y� �- _ . ` , � _ � _{ __ � - _ �_ __ . _. - �:�L/a �b���
j - - -� - - - - - - - -� - - - -- -- - - - -
N - - _ - �fiAT'I�TE _SO�L �-- ^- � _
1 - . .' ' . ". _ __ _ _ _ _� . .' __ '_ - ^' .� _ . __. ._. � ��� l�wl{v��
1—'—.
Project Dennis Renley
- N
Typic�t flispersai CeN1,c,x,/
tintci�cd C;radc �'�`i/ 4-�Y Y ��'�?�i�
r _
�=��
, �2 n..�,::� ��---_:,._�a�;�-�a
�_=��-�_>_,t �--_
�
- -� .- ---- � v:s� - ���:
--- � -�_
7�of�eorr�bDbe at or _ -_- ---_�-=�.-�---�--�--�. E_ --w tr�.-
��,�t� _'.�.:�'��s --'- _ �.--�=:
-- - -�_=.-�:=-
� NATI�lE SOIL - - -
T - -= Z�:Y�:s.�:
�� $���
1����
� i � Topsoil Cap
TO�A""�' f°��0�'� � � 5ubso"si Cap
� � ? �� ASTM C 33 sand (F)
�"` -t Q ASTM C 33 Sand {D)
� - � � Tetied Layer
r� �� •'"'•" ' ` � t� � Geo Mat
�
_ ••—�l �ag.�r�L_ , jt"
�i�;,�;�',f;_.,.;?- ,- -_ ---,
�:ft"��":;a����t=��. '
Pnijec� Deraas Rereey Page 6 of 19
Number of observation Pip�Per distnbation cell » —
Loraxion of observation gipes Oa tog of ti�e sand at the very end of each cetL
i. Have an open bot0om
2. Havc a nominal pipe size of 4 inches
3. The lower I inch is slatted ar perfo�ted
Desigtl a�i inshall$iion of obsetvation pipes it�stted �_ SlotsJholes are>l/4 u�ch and 51l2 inc1�in c�idth
in GeaMat Systein and Iocat�on opposite s-ides
5. A�hnn�in a manner that w�l prevent the pipe fram
----- ___
being pulled out—t�se toilct flange
- ------_�
Jt'
Cerrbe�Connection la�era!la�nert Diagrarcr
_�
, ��.
r=-�
� - - - -� - - . _ _ - - _ - _ - -� _ - . _��
\ - _ - -
fi _
- - - r�nr- - - -
NUMBER OF lRTERAlS=4
LATERAt.DIAMETER .
G�avif�'sy��y use'T�1e s SPS 38430-�.A�I Adm
Code.
If gir��it�sy�ase t�c�ninnrfu siae ofRSTM I785 Pipe
atbwed is 2�vv�a ma�nm►m uf 4 i�ches.
Adc�ti�Ily,%h i�h ofifices shall be dn�t m t�fotyowiu�
�:
Thepi�shull�raue 2 mx�and anly 2 rrnus,afarifices
p�ullet m tlre aris ofthepipe mrd 12D deg��/.-S degrees
�t�ue other x+nnts thepajo�araaons shall be rit die
nomuutl4 amd 8 0�p�ilions�vhen the pip,e ir vrstaTled_
Perforations shall be�ced ever i2 mches. Larst a�ce sha
be<12 indres fram tlre�ofthe Geo�Crt Tlris prrnnotes
equrrl distrit»�ton ingsavit�ssste�nr. IfTablex SPS3843f3� .
u u�lateml cle�m�t will be ne�ded.
LATERAL LENGTH=�FT DISTANCE SETWEEN DtST_ PiPE EIdD ORlFlCE AND END t?F
DtSTRtBUTtON CELL=12 tNCHES_
CELL SPACtNG=1 FT:
k}�/4Q�R +LENGTH=425 F?
, �
In Ground System Maintenance and Operatlon Specifications
Service Providers Name Northwest Sanitation Phone 715 945 2650
POWTS Regulators Name Sawyer County Zoning Phone 715 634 8288
S�rstem Flow and Load Parameters
Design Flow-Peak 450 gpd Ma�dmum Influent Particle S¢e t/8 in
Estimated Flow-Average 300 gpd Maximum BODS 30 mg/L
Septic Tank Capaaty 1000 gal Ma�cimum TSS 30 mglL
Soil AbsorpBon Component S¢e 162.5 ft Ma�dmum FOG 10 mg/L
Type of Wastewater pomestic Maximum Fecal Col"rfortn 10E4 cfW100 mL
SeMce Freauencv
Septic and Pump Tank Inspect and/or service once eve 3 ears
Eflluent FiRer Ins ect and clean as necessa at least once ev 3 ears
Pump and Controls Test once eve 3 ears
Alartn Should test riodical
Pressure S�+stem Laterals should be flushed and ressure tes[ed eve 3 ears
In Ground Inspect for ponding and seepage once every 3 years
Miscellaneous ConsVucUon and Materials Standards
1. Observation pipes are slotted and materials confortn to Table SPS 384.30.1,have a watertight cap
and are secured in as shown in the GeoMat In Ground Component Manual Ver.t,2017.
2. Dispersal cell media confortns to GeoMat producls approved for use with the GeoMat In Ground ComponeM
Manual Ver.March 20,2017. Media is covered with an approved geotextile fabric.
3. All gravity and pressure piping materials confortn lo the requiremeirts in SPS 384,Wis.Adm.Code.
Lateral Tum-up Detail
68"Diameter F��nry� Threaded Cleanout
Lawn Sprinkler Grade \ Plug or Ball VBlve
Box y
Wte21 Ends at lart Orifice Where
Long Sweep 90 or Two
��45 Degree Bends Same
Diameter as Laterel
//
�
Distribution Wteral Lateral peanout
2 Feet
Project: Dennis Renley
I
Notes/Maintenance Reauirements
MANAGEMENT PLAN
7his pnvate onsite wastewater(POWTS)has been desgrred,and is to be instailed and maintained in axordance with SPS 383,Wis.Admin.
Code,the in-GrounA Soil AbsorpUon Component Manual for Private OnsRe WastewaterTreatrnent Systems Version 2.0 SPS-10705-P
(N.01/01). GeoMat fn ground Component manual VersioM.
7.This POWTS has been designed to accommodate a ma�cimum daily flow of��ns of wastewater per day. The quality of
influent disc�arge into the POWTS Veatrnent or dispersal component shall be equal to or less than all of the foibwinq.
A monthly average of 30 mglL fats,oil a�M grease
A monthty average of 220 mgfL BOD5
A monthly average of 150 mg/L TSS
Wastewater shall not discharge to the POWTS in quantities or qualRies that exceed these limits or Mat resutt in exceeding the enforcement
standards and preveMative action limits specified in ch.NR 140Tables t &2 at a point of standards appliption,except as provided in DSPS
383.03(4),WisAdmin.Code.
2.The owner of this POWTS is responsible for system uperation arM maintenance.
3.Defects or malfundions identified during maintenance described above shall be repaired in conformance with SPS383 Wis.Admin.Code,
and the pertainirg county Private Sewage Systems Ordinance. The usets manual,provided to the owner of tbe POWTS inUudes the names
and telephone numbers of the properly licensed indivaluals to contad for such 2pairs.
5.No product for chemical or physical 2storation or chemical or physical procedures for POWTS may be used unless approved by the Dept.
of Canmerce in accordance vrith SPS.384,Wis.Admin.Cotle.
B.If the POWTS is replaced,or its use discontinued,it shall be abandonc�cl in aaordance with SPS 383.33,Wis.Admin.Code.
NOTES
Two EBiuent Fltters to be installed whe2 possible 1 to be installed in ST,and or 1 in pump tank in
order to insu2 particle size less than or equal to 1/8'. Fikers should be cleaned once in spring,and once in fall. Also,strainers in sinks in
the buildirg shall be maiMained,so fhat solids arM fats are minimized to flow into sysfem.
A minimum of 2 observation pipes per cell shali be instailed. These pipes shall be bcated approximatety at the end of each cell.
The piumber,or county shall see to d thffi a copy of lhe5e plans including this page,maintenance folder,a�d maintena�ce agreement is
grve�to the homeowner.
This system may contaio a dose chambec If a pump,float,eleUrical outage puses the dose tank to fill,the homeowner should see to B that
the effluent level in the tank is DrougM drnm gradualty and not all dosed to the system at once- One large dose couW cause damage.
Contact a Dumper or your insfaller'rf this problem oaurs.
The homeowner is responsible for formulating a water conservation pWn that will ensure the system�s rarely oveAoaded. I.E.spread Yaundry
out over time,not 6 bads in 2 hours,while everybody sbowers,and uses the toilet,ETC.
CONTINGENCY PLAN FOR COMPONENT FAILURE
0.Septic Tank.Any structural failure resuking in cracks or ieaks in the tank must be corrected by replacement of the septic tank component.
Leaks in the jdnts between manhole risers or covers shall be rapaired by repladng fauity seals wiFh approved materials to make joints water-
tight.
B.Outlet Filter.The outlet filter Shali be 2placed or 2paired when it is eilher no bnger capable of preventing the discharge of partides larger
than 1/6 inch or when it has become permanently degreded by cbgging so as to intertere with the desgn flow out of the septic tank.
C.Dosing chamber and pump.The tlosing chamber shaB be replaced'rf any sWctural failure is tou�tl.Leaks in joints between manhole
risers or covers shall be repaired by replacing Naully seals with approved materials to make joints water-tight.The pump and controls shall be
replaced when they are no longer caDable of functioning according to Me design plan.
D.Pressure Distri6ution Piping.Partial dogging of the distributlon network may resutt in unduly long dosirg cycles.The ends of the
tlistribution laterals may be e�osed and the threaded enC caps remrnetl.The piping can be disconneUUed on the outlet end of the pump.
The distnbution piping may then be back flushed to cleanse any accumulated matter from tbe piping.It is recommended that the dosing
chamberthen be pumped by a licensed plumber.
E.Soii Absorption Cell.The discharge of sewage or wastewater to the grouiM surface is sUictty prohibited due to the human health hazattf
created by the eRluent.All faiWres createtl by surtace discharge shall immediatety be reported to Me appropriate county.The pump shall
then be immediately disconnected to prevent further discharge to the ground surface via the soil absorption cell.The ewsting septic tank and
dasing chamber shall be used as a temporary holding tank until the necessary repairs to the soil ahsorytion celi can be achieved.The
replacement shall be initiated only afler any necessary pWn approvals have been obtained from the
appropriate plan review authority anA the required sanitary permd is o6tained from the county.
Project: Dennis Renley
�
- USE BLACK INK ONLY - II!iII���I�I(III III I(I IIII III
C��cId:8G5"���
POWTS HOLDING TANK AGREEMENT ix:�040703
RELEASE �41326
PAl1LA CHYSSER
Owner's Name(s)as shown on deed: REGISTER OF DEEDS
SAY4JYER COUNTY, WI
pQy�y�ls D . ��n�� +fl9I24J2022 lU'.52 AM
Parcel Identification Number: RECORQIAIG FEE 3fl.00
(12 Digit Legacy ID) 0 3 �- 5S 3 9 - .2"? - Y 3 � .s
— — PAGES: 2
Legal Description of Property:
-SEE ATTACHED SHEET -
Return To:Sawyer County Zoning and Conservation Administration
10610 Main St.Suite 49, Hayward,WI 54843
��xc¢. �ez.� entered into a POWTS Maintenance Agreement for
Holding Tanks on o3�a$ ��12 (date of Agreement) `�38.333
(document number) for Property located at � -��3 �/ �4� t..�;,��- ►Qd ,
(address) and as described and attached hereto.
This release, signed by an Authorized Sawyer County Zoning and Conservation
Administration Staff, relieves the owner and property from said Agreement as they have
obtained a sanitary permit to install a non-holding tank POWTS. The current owner, their
heirs, successors and assigns agree to abide by Wisconsin State Statute 145.245 (3) relating
to pumping of this new system.
TIMOTHY R SEIDL
NOTARY PUBLIC
STATE OF WISCONSIN
Authorized Signature:
� State of: �,J �;�—E�,^`�; �1
Authorized Name and Title (Print): County of: � f-
L���� We a�' Ca� -�n���a Subscribed and swo7`n to before me on this �'y" day
Date: of c�t��ti r��:.�,r , 20 ���
p� � l 3 a�� By: - ���� � G�e:� r
Drafted by: Notary Public Signature: ' �
£�`� �/'�`�a�— Public Notary Name (Print): ��' c�,
My commission expires on: ' �� �(�o
Personal information you provide may be used for secondary purposes[Privacy Law, § 15.04(I)(m)] Rev. 03/26/13
Lot 2 as recorded in Volume ]4 of Certi�ed Survey Maps,page 376,Survey No.
3617 as Dacunient No. 233229, located in the Town of Winter, Sgwyer Co�znty,
Wisconsin, being� part of the S%aSE'/,Section 27,ToFvnship 39 North, Range 5
'West.
„'�"=�=�`"�����; PRIVATE ONSITE WASTE TREATMENT county
��,;
=� �S ,�', SYSTEMS Sawyer
, ps ; ( POWTS)
''� � _��,'
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� ��-- INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �� _ �C'��o
Personal infon�ation you provide may be used for secondary purposes[Privacy Law,s. 15.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village �Town of: State Plan Transaction ID#:
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Insp BM Elev: BM Desc iption: Parcel Tax No:
I�-6� Nq< < IY” �q1s4� `�.-Q— 032 , s3�-,�7—�3�5`
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic ��p Benchmark �oa,o�
Dosing
Aeration Bidg. Sewer 4"J.oS `
Holding St/Ht Inlet q(�.�i3 `
TANK SETBACK INFORMATION St/Ht Outlet 4�.SS '
TANK TO P/L WELL BLDG vENrTo ROAD Dt Inlet
AIRINTAKE
Septic �5` +�S` N � N /� NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man. �6, I 3 '
Hoiding Dist. Pipe q6.oS �
PUMP 1�IPHON INFORMATION Infiltrative �
Surface �y.6S
Manufacturer Demand Final Grade
Model Number GPM .3 S,�S �
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist.To Well
DISPERSAL CELL INFORMATION
DIMENSIONS W j a` � 37 #of Cells Type of System Distribution Media Manufacturer:
Conv ❑ Aggregate
SETBACK P/L Bldg Well OHWM of Nav � �GP � Chamber ����a
INFORMATION Waters � AG ❑ EZFIow Model Number:
CELLTO � �'��� Sj t'(ap ❑ Mound � Other
— - - - -- _ _ —_ _ --
DISTRIBUTION SYSTEM X Pressure Systems Only
— -- -
Header!Manifold Distribution Pipe(s) �Hole Size X Hole Observation Pipes i
Length Dia _ Length Dia Spac Spacing ❑Yes ❑No J
SOIL COVER �
- ---_ - — - -
Depth Over Depth Over Depth of Seeded/Sodded Mulched
-
Cell Center Tell Edges j Topsoil _ __ ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
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Plan revision required?�Yes� No d�i p� �3 � < �� 6���(�
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A��ITIDNAL COMMENTS AN� SKETCH
SANITARY PERMIT NlJMBEA:_ ��__�O�__
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