HomeMy WebLinkAbout002-940-23-5309-SAN-2022-252 C
Counry �
Department of Safety ��,� � �
9 & Professional Services, �
5� Sanitary Permit Number(to be filled in by
E Industry Services Division
_ �0 3°l a 3`7 St,
Sanitary Permit Application State Transaction Number �
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 permit Note Application forms for state-owned POWTS are submrtted to Project Address(ifdifferent than mailing� (,fl
the Department of Safet}and Professional Services Personal information you provide ma} be used tor secondary � p ,
purposes in accordance with the Privacy Law,s I�0�1(I)(m),Stats. ������ / �S �J
I.Application Information-Please Print All Information «�
Property Owner�s Name Parcel#
I,t)�l l i�rv1 �• '� 1�1 e(thC�4 �.i�1�;,1 Z��.v� p D 2�`l�E D�-2 3- S 3O 1
Property Owners Mailing Address Proj�ty Location
�'7 ( t,11, (�.F� S f. f?...
Govt.Lot 3
Ciry,State Zip Code Phone Number
�'/�CC�.(S j(J1� YV�N .S S.�3 I �P(2.- �� � rC�Z� '/<. '/., Section 1-.�
IL Type of Building(check all that apply) � Lot# T �� N R
`�or 2 Family Dwelling-Number otBedrooms Z �" � Subdivision Name
Block#
❑Public/Commercial-Describe Use
❑City of
❑State Owned-Describe Use CSM Number ❑Village of
I� /��y � ��� �To�m of_ _ - -�_
III.Type of PO��'TS Permit:(Check either"New"or"Replacement"and other applicable on line A. Check one box on line B.Complete line C if
a licable.)
.a.
❑ New System ��Replacement S}�stem ❑ Other Moditication to Existino System(explain) ❑ Additional Pretreatment Unit(explain)
TV�N�Z 6N is( �
B' ❑ Holdin Tank
g �1In-Ground ,L�� ❑ At-Grade ❑ Mound ❑ Indi��idual Site Design ❑ Other Type(explain)
(conventional)
C• ❑ Renewal Before ❑ Revision ❑ Change of Plumber ist Previous Permit Number and Date Issued
❑ Transfer to New Owner �
Expiration �5-23`f l'J�i�v' �s!'� cJ;c f."'Z' �
IV.Dispersal/Treatment Area and Tank Information:
Design Flo��(gpd) Design Soil Application Rate(gpd/s� Dispersal Area Required(sf) Dispersal Area Proposed(st� System Elevation
�� � '7 �`{3 c uKk. ? �.� u�k �k�s
Capacity in Total #of Manufacturer
Tank Information Gallons Gallons Units � ` o � ;
New Tanks Existing"Canks '� c v � � � � �
0
a U v� � v� u. C7 a.
Szptic os-#�eldipg Tank � 2
Dosin�Chamber
V.ResponsibilitV Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans.
'�lum,b�j s�Name(Print)��n K��,c -t Plumber's Signahire MP/�PRS.Number Business Phone Number
. KL.��i'�.uss..e�,��C Co 7 S?S� 7(5=74.�- �3 S3�
Plumber's Address(Street,City,State,Zip Code)
- C� ._ i�'�c�= �'CF ������ `t,�.'� S��' 2("
VI.Co nt /Department Use Only
�A�fch �D�sapproved Permit Fee Date Issued Issuing Agent Sienature
�1'� ❑Owner Given Reason for Denial $ �O��Oo � /'� I�a �
Conditions of Approval/Reasons for Disapproval �---1�r-a �.���i�-r-a�—.,-�.-�
NI G 1 ,�I ,�\i,� �-r�
._�� � °I >� J �� �, '''== �'�'---_�'7��_�v �f�
� Y a a�.>� �
�IGII�V� J�
�� Chk# �
a AUG 0 � 2022
C s� ��'• ,�3 RCpt#_I�-� w�or l c1 � 3�-f l� S�1�1JY�F-5 C011NTY
� � ��tdING ADi4�iNISTRP,TIt�N
soi� Attach t omplete plans fo�e sy tem and submit to the CounN only on paper not less than S 1/2 x 11 inches in size
S v�ri`���a� 3'C�l o
SBD-6398(R.03/22) �--����,� NO R�FJNDS AFT E R
,,��1� � ql�Y��'ISSUE OF P�kMtT
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): l!) i_ 1� 1Q�� ��. � �1�.(i�lciet v �I'lu�c1zbe.,,^q Phone: �I � - � lv _ c�C21
OwnerAddress: l�l t�t�' , �- � �Xc�jS�o�, fN.� Zip: 5�533 �
Pro��t Address: lit4�lu% � s5 (2C.� � �e�,r-u1c�v�[�.. W-� ����3
i.�ri's �.�3
Govt. Lot: � 1/4 of 1 /4, Section � 3 , T � N-R q E or W
Township: ��qsS ��. County: v�.�;t��e..�'
Project Parcel ID #: c�L - �t,�-D� Z3 - 5 3 oq
Designer Information
Designer Name: Ia�G�� �u-��-f�- � Phone: 7►s - 7�� - 33s3"
Designer Address: �- �. ��C � � �����t-t-'� Zip: S�� �
E-mai I: -�-�rv(� ��;� v , ,�cc s ; �oc�
License Number: � �� 5'� S �
Remarks:
Signature: Date: � � zz
Original sign r required on each submitted copy.
PAGE 1 OF
`1�1 l��ICIVYI 1�d �����C�Q J. m�.IeYIL��
�''I I u;es+ (� ��
C�:ce-�siov�� M� 55331
C�iz - S��o-i�al
��i�k u) C7oss RA 'k �c�;�,� Rep��c�a�er�f��-
Sa3,T'�.{oN, �2qW eXis�-I�y �1L' 'k
P-�-a F E.L 3 (s�i's :e d 3
C:Sm �y�li4 '� s�zo
-(`owv�oF l�'AsS �c�l�e
Sa.a.v,y�e.,r �a.,w r r1oR�
�d02-a�Eb-2,3 - S30g SCpS.E. 1�� = 40'
�-1
�c To (�u P��C', 6�� 5�ec( ��1� l CL�1� �.
L
'� PvoPc�se�
_____ -___ __ E�b��y � �,:i ESEO--
�`�---_-_ (OCC TYrNiGu'/
l"�vr< nf�e Ill '
/ B3 - _-i- � �o oY�;nce
I I — �;l�-�'
����ic�.5 l
S� �* q$���y uzu.r B1�.otr Ex.
CSr � q5 2 .;'_ �2 HOME
��rr 3 i�� Cx�u� l�cus,_� �
C.\.��<. ' lh.;� <1( �er
.CCESS ROAD 1
� To Goss Road �'L� �
tTQ56h�•t�ei-E�I V1'�1��(�15`7Sl
2" SC�1 90 PVC 8(2-/2Z
�RCQdAIN
�B:�1.-Bottan of Wood Siding @NE Corner
�
New 800 gal. pinnp Exist.
[Vew 1000 gal. septic tank 3BR
Ho[ne ' �
---." Q21NDS'IONE T s+�'
� PAGE40F4
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 activities shall be performed by a registered POWTS Maintainer in
accordance with SPS 383.52 (3), Wisc. Admin. Code.
Maximum Dispersal Area Operating Limits:
Design Flow = �f S� gpd; BODS <_ 220 mgL''; TSS <_ 150 mgL''; FOG <_ 30 mgL"'
Inspection 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 treatment tank(s) and any distribution appurtenance(s) (i.e., distribution / drop boxes)
o neglect or improper use (i.e., exceeding design capacities, prohibited activities, etc.)
o extent of ponding in distribution 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)
c surface discharge of effluent or sewage back-up into structure served
Maintenance Checklist MAINTAIN EVERY 3 YEARS (or when necessary)
o Septic and dose tank(s) 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 � 13, Wisc. Admin. Code.
o Effluent filter(s) shall be inspected every 3 years and shall be cleaned 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: tt. f�GS�'1,t.tSS-�atid S&1S Phone: '��S-��.��` ��SS�
Local government unit: �G�,:;ye:.� � ��'� Phone: '7� S-(n 3 �`�2�
Local govemment unit address: �-ti.Lc,�-���Ci✓'lii � �-�%i ZIP: _�{tS�f3
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.
Contingency 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.
System Abandonment
If use of this POWTS is discontinued, it shall be abandoned in accordance with SPS 383.33, Wisc. Admin. Code.
� ��
�� ` Office of - .
:ti' �
� Saw er Count Zonin Admini tr '
y y g s ation
�
10610 Main Street Suite 49
,�������� Hayward, Wisconsin 54843 f z 1 F; A,. _ .
+ fG'R �Q 11 (�15)634-8288 �` � ¢t* � '
� � � 1 , r � ' �r Z rr'?
�� ����.�I FAX (715)638-3277 : �f� . 1 f t ' -
� Q . \,{�� w-wtiv.sawyercoUntV�ov.org .� � � ;
�tA � � � �� �� � E-mail: zoning.sec(o�sawyercountvgov.o� �"'r �y�� „"^� � � � �i v � i
„� o i Toll Free Courthouse/General Information 1-877-699-4110 ' � ,� �r� " � �,
�� o \ I ,� • --..
���'�� : � `�� } ;.��a�k :�+��' y Y;.
�t i i`o�`� �.�'���.� ���,a�� � �q(��;� � sr--
� :;7'S�t A--•.
--#l;s-�n
,vry
SAWYER COUNTY SANITATION DEPARTMENT
TEMPORARY EMERGENCY TANK INSTALLATION APPROVAL
PROPERTY OWNERS NAME: �I�� ��a� I� �- �/(/�Q (-n�q �� �/V� tiQ
TOWN OF: �4SS � 4�—
ADDRESS: �I �(� �Y� �aSs Y� .
/�'. �
I, ���.=�" v �� , a Wisconsin
Licensed Plumber, auth rized by the wner, do hereby acknowledge that I am receiving
temporary approval to install a septic tank/holding tank without a soil and site evaluation,
or existing system evaluation, 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 plan review will be conducted by the deadline stipulated by the
permit issuing agent, or as soon as weather conditions ar circumstances permit. If the
private sewage system is found to be failing as defined in s. DSPS 381 .01 (92), Wisc.
Adm. Code, corrective measures will be taken as such that the private sewage system
complies with all applicable requirements of chapter DSPS. 383, Wis. Adm. Code,
within 90 days of this agreement.
I further acknowledge that failure to comply by obtaining all necessary permits after the
deadline date may result in the issuing of a citation, under Section 11 .3 [2) Sanitary
Permits], of the Sawyer County Citation Ordinance.
DEADLINE FOR THIS AGREEMENT SHALL BE: �d� t-3 / �a
Signed: '� ' ,'�'
Date: � ' �3 f oZ �
Accepted by: `
Date of temporary emergency approval: � I 13 I a—�
Rev. 03/26/13
Real Estate Sawyer County Property Property Status: Current
Listing
Today's Date: 7/6/2022 Created On: 2/6/2007 7:55:07 AM
Description Updated: l2/17/2019 Ownership Updated: 12/27/2017
Tax ID: 3610 WILLIAM H & EXCELSIOR MN
P�N: 57-002-2-40-09-23-5 05-003- MELINDA j
000090 MUENZBERG
Legacy PIN: 002940235309
Map ID: :3.9 Billing Address: Mailing Address:
Municipality: (002)TOWN OF BASS LAKE W�LLIAM H & WILLIAM H &
STR: 523 T40N R09W MELINDA J MELINDA J
Description: PRT GOVT LOT 3 LOTS 2-3 MUENZBERG MUENZBERG
CSM 19/114 #5620 171 WEST LAKE ST 171 WEST LAKE ST
EXCELSIOR MN EXCELSIOR MN
Recorded 1.620 55331 55331
Acres:
Lottery � Site Address * indicates Private Road
Claims: 14944W GOSS RD HAYWARD 54843
First Dollar: Yes
Waterbody: Grindstone Lake property
Zoning: (RRl) Residential/Recreational pssessment Updated: 9/13/2012
One
ESN: 406 2022 Assessment Detail
Code Acres Land Imp.
Tax Districts Updated: 2/6/2007 RESIDENTIAL 1.620 445,000 218,800
1 State of Wisconsin
57 Sawyer County Z_Year
002 Town of Bass Lake Comparison z021 2022 Change
572478 Hayward Community Land: 445,000 445,000 0.0%
School District �mproved: 218,800 218,800 0.0%
001700 Technical College Total: 663,800 663,800 0.0%
Recorded
Documents Updated: 2/3/2014
WARRANTY DEED Property History
Date N/A
Recorded: 6/22/2004 322601
CERTIFIED SURVEY MAP � , �� G(��'` :
Date 262164 `
Recorded: 7/28/1997 � ze-i�l�
`�`
,�l,t.I� � �(� - ��� �,�u�:
���"�.S 2 �Z' (Ztrn)
-� �� �z���
;.
.:�;�
� .�yy}�.
_S.l KM�L. �.�-�., . ♦a. ..
i �Jf�� ��� � ' •� �
y` 4
� T y,
yg��! �`� a
f � *'%d..�J '.. • ,�J! ✓1 '�
i �
!f� � f r ��y,. Y��J;'�� .. \x:a .
�� � t � '�� / i i ""'< �
�
j.l:r t. j` � �� �h' y �; ,
�- ��f' J�, i.G t � � �' :_
� r3.' '\ y 'd .3.. .�� �J� r �\ T � '�u�:
.� �. ,t 4 ,`4\' ` �-� ��"'�`;: , s
h��.:� fd' x�" ' ,.' r` � �� +��3�*
� ��'S ! �(:�_. � � > �.�+kM � � � � �4
I i ..� ��^ � ,.� ,�».*�� j•�
.v a� �' P�'r �. ,-.. 'l � i, z�' ,� �> .
�� ���� �/
?•�4 .Y.�.�.. �_'�Y ; �,�sJ,�l J► I�Y:T� �j �
� e��.. �\� � .rr
. r��'"✓�s r .� ' � ^ .. � l�� I
�'i irt �'- �1 r'- '� �."�� ir4, sT �,.
���,, � Y.�'
�f i �..
�'� ,�� '�tiE"� ��y' � �y*\� },�;.�j `.!.+'Nt:f .+'!(�; (�r ..
� � s __��.��`.`' :,�0 F .,ti;�'',t Jf a�l.
K r
,�.f �i�. �i' � ,�' I �5�� ' .
�� f 6�Y 1� �'� .'3✓J l,�Y����`
9 1
i
S.
��� � :s � wx 1f �s x -,�'l ,�•} ���, , �
lrC''r /.% -•�.♦ � � Y�-.� �',, . �.I��� .t.� ;n�.a��_.
n a
.,,.'o'V l Y� f" c �� �
��. x �/I/�
����'. �=— , � �'"9+ � � r �St� � ���F���.
:l-%�"J1w� _�`\ � � ,�� - �J� �t '- , .
��'�c��;� `� �� ���,,✓ 7�4 i `,'�d?�` .t �' a
y. � .: �,,`•'�` :�` , yf * .y w `
. `r' ./�i,(s _ ��-. ' ��LM > r, .sG � /`�y �1�' �a,� .
.3�l�'�s0�'���� � 'y �.�� �'�i S.�,j���ti w �.. � �,�, R��, _rr
a
! '1 ��°'a0;tv !hA'� l`Y, . t a .r � � �(vA_�da^�"`.
q .��� z�. J i W- 'i� - , 1�'�,�"���`...�� .
. i .���i �` ,fy Tt , y ,.� �_-.
;� . y� \ r.�`" _�.7'.,p c . 1 *f f=R1�,� �!' ����: ,�/C.`.�',�. . � � ._�.
�� �., L� j 2� r,� — -;s--
� ��`� ^ �r.'f' �1J ,�. -.'_=- ,,,,,. `>.
� . � :� r> � t � �'�''. �.-f �ry�'��=+`•��O�g, >- �`�
�� 'Y`" � t'i�,�'€'. f J� �.� 1 �7t's..�'.T '" � ,. '��� 7 1_ �'__ "'�`s,�.` !
r , � +�///� '"��.5�.�.
� "` '� ;�� { , -''��" �' ,� �RP �''Tf'''T"�'.',Y
! �� „ `^+� x � - ; � 5r, -'.F � `—
.� r }�
- -�� .- r l ✓,+ � � _. '��"'��fF, . . f� , ,,rl,"9��.— 3g�r-p��•:
:�, .i,r -- � `5�� �� '�� �. , ``��4 x��� ,� �",
'r i / -��"'' s �'g ��y .;, � �1���1 ` � ,L::. .
�- �- �,i��� �
, � � � � � � � _
� � i � �ra � = , � � ,�,�, , �
� . �', v / ��t ' ��' + N�. .. t�/`e '�''�,`, �'' ���y'.
i / ' � r r a,Fe�,=
T a�s .*+�,a�' : rt . S'u ,�p 1-n 1 , r'.��' ,4 �
���r.' ,.r � r;.l s' �� ��xF ,q �i°2k,3��s .,- t t� �� / �s.,,.h� ./ '� ��T� .
% . �' � . r � . ,p 7 i
� �v .. � /�.�� l"' r -Y�r�.Yus� �r. .:;� /yE �IJ�Z � . . 'd�,
.� y , /i w r •3 i��'� "-" � � ,�i �-f .�y ...,,��y� �.:" ..^ � i c�'. .3'�,
i +"r i Y� 3 I � � .� r ��t+�,�
,.r '-4r�� , �f fr �/ f... . .� .} �i�, y f j nti �,, h -
/44 .s'f� ,�" i �(/r� 'f 1 �'y,�F��/ ' T��'}�` ^�Q, � ,ry 7'�' 3 yyi l .}i 8
:FJ�'� i :i �+� �+P4�1� i .�: n 3 ,. y4 .. .l� �t�'F _
� },�" �,�y �� ti l ��, �� i��f .' ia� '* ; �'� :J'�'�Y � '<
� �� y ��
-G '1'':� " 'f � `�y'R.�F � f,. �r�/S,� ,�{-r ✓ h -� ���=y�y�.+ ,�f -
,.��°• n i�.•-�: . �`1�: ,ifi ��N ,'; ���,
.r ..�r. ',r-
.. "`'" , "„ ° f01S ry SOIL AND SITE EVALUATION `
- i-aSor�:ind Human Relations a Page�
Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. C ST �I S� �3
Attach complete site plan on paper not less than 8 7/2 x 7 1 inches in size. Plan must Counry ""� �
indude,but not limited to: vertical and horizontal reference point(BM),direcUon and �
percent slope,scale or dimensions,norih arrow,and location and distance to nearest road. Q�� P�
� Parcel�I.D.q
APPLICANT INFORMATION - P/ease print allinformation. Re�ae� y0 . 9 � 3 .3
Y Date
Personal infortnation you pmvide may be used tor secondary purposes(Pnvacy Law,s.15.04(7)(m)).
Property owner �'`� Z-t4-9S
PropertyLocation NG SE a3 `zo ,1q,
� � C ❑ Govt.Lot 3❑ 1/4 ❑ 1/4,S ❑ T ❑ ,N,R u �W
Property Owner's Mailin/�Address Lot ti Bbckit Subd.Name or CSMN
�� � �.7� 0 /
��ty State Zip Code Phone Number Nearest Road
l�� w�� ;( c.✓� SYBy ( 7�s') G3�Y9s's ❑ c�ry ❑ v�9e L� Town ;ess iP�O
❑ New Construction Use: �Residential/Number of bedrooms 3 Addition to existing building
0 Replacement ❑Public or commercial-Describe:
Code derived daily flow ys0 9Pd � Recommended design loading rate . � bed, d/ft2 - �
9P trench,gpd/ftz
Absorption area required � `�3 bed,ft2 r6-?-Srench,ft2 Maximum desi n loadin rate
, , 9 g �bed,gpd/fiz -� trench,gpd/ft2
Recommended infiltration sudace elevation(s) �. S ft(as referred to site plan benchmark)
Additionaldesign/siteconsiderations ��oHv-.�7��0., � SvS��--r w�Li�� S�n{
Parent material ���rci,/ T// Flood plain elevation,if applicable �� g
S = Suitable for system onven i Mound In-Ground Pressure AT-Grade System in Fill Holding Tank
U = Unsuita6le for system �X S ❑ U ❑X S ❑ U � S ❑ U � S ❑ U x❑ S ❑ U ❑ S � U
SOIL DESCRIPTION REPORT
Bonng # Horizon DepN Dominant Color Mottles Structure
in. Munseil Texture Consistence Bounda Roots GPD/ft2
Qu.Sz.Cont. Color Gr.Sz.Sh. ry
Bed , Trench
l �` l o-� ��sY/� 3/� n�. , �� 2k6,� a s �� . s ��� �
- .�__ ,� 2 Z s 7 Sy(' Yl�� �t�n e S �s� �,� c S — �
Ground ��3�
_ 7 - c
elev. � %2 3 �2 /�on L s �)c� an� C 5 c� . � , i-
i`�--7h_ y 3b 90 � r/2 Y/� — �
��e�e S C�� <n ( — , �
Depth to
limiting
factor
�%� in.
Remarks �,Vu�� cl, as� f�o-���.,� �rc��
Boring # '
l i�-� -7sY� 3 / � oott SL � �
,� �fsl,/< ; ✓�� C5 3�, , � ' , L
;� G-a� �SYJ2 <1/C� r��'�� S C;s�� v� ( c s `,�« _ � , �
� � � I :Y �7 s y/; s�Y ,;��,�< L� i�c, ,:� � c s J« � � -
Ground `j 37�/ao 7S� /� Y�Ce s�4ovr-� — — �
elev. S c� C/S� ..�� _ 7 c�
�o .frh. '�e�, L�' �n�l, ,
Depth to
limiting � ,
factor
�i�'a in. Remarks ��o��z�.ti 3 — �,r l
»� , � ace
CST Name (Please Print)�� � Signature �
Telaphone No.
JO �-:. �is- 7Gr- �/Go�
Address R R #1 , BOx 139A Date CST Number
, . � r�-�'f 3�73
SOIL DESCRIPTION REPORT �
, OWNER Page v� of �_
:L I.D.#
c30f1f1 # Horizon Depth Dominant Color Mottles Structure p 2
9 Texture Consistence Boundary Roots
a in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 6ed , Trench
,
:�3 ° l v-� 7syR 3�� n�;�-e 5L a�s5.� ,�,� � � s 3 �� . 5� � . �
�.��k ,:
#;x,�,.,,, ,..;;;
� �- 3� 7Sy� � /�r-<- L S ��` ✓n � S ��� ,7 � �
Ground 3 0"&� _S�YK `f(� ✓�Oy� �Su� �� �tl C i� - 7 �- �
elev. I ,
/os7ft, y e-f�o � T � Y( �oh� C S �� vyr� � --- _ 7 �_ �
Depth to
limiting ,
factor �
���° in. '
Remarks: /-�v�-�2,�, s /, � -� 3 — c� � s�
Boring #
Ground '
elev. ,
ft. �
Depth to
limiting �
factor
in.
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Boring # ;
, ..
".. _
- i �
:�,
Ground �
elev. ,
ft.
Depth to ,
limiting �
factor
"' Remarks:
Boring #
Ground �
elev.
ft. '
Depth to ,
limiting
factor
in. Remarks:
SBDW-8330 (R. 03/95)
�
�Sb'i�t—L -a�n� ��,o_(.-Sr,.+�.�� �b_o/-L "''2� ����
l
--------_
j�"_ � \
;�.�`�'�' � �G 3� �l(/�-5.� �"''� %"�
�� ,��>.
't� '`� '-
\
f
'
/
I s�1z`� ��--��
� �'S•;
IL��..+Z^�J�
I`
�,,,�,:�j 1
1 � _ � t,�
�' ' � • � � /��`��I+.�GLro7T/J
\<J �`��'.` ��.1 � ..= v /
� � '� � �,d9� �s x� �! .
�
� 7�.�s�h� _ ,�r���°SG ���5 osh _
;
�
� �s��'e/�� � -�__�.�----_�
_ ��
-_-
--_�-��a��=��`` .� i s���� ,����'�'a�w'o�a o/
-_ .-��_�_ �— — u U _
���-_•..�_—__ . � " ------ � A�� ��� J �G,a 1�.i d��✓/��i+ t,.�o.�}��� � �
�j' / 9
,s�bb
_ �•�����a�� ����s�5 _
��a��/ /�'.'Y7�,� �� S/ >�.�f� ,��t�
� �b _ z,..�,� k,,s+ f'I f��� .�r�35
U
,�. �Sn/ = �.�
, � ��1 - ��1
� � •�oi � i�
— s�o��>�na�� —
/�,�d/ �...,o�b Tn��, S_S`�toe�✓ _ 'o p J ` a�y� ��
i /
.�auapJ �/y ✓!^�/�)5 �ooM �p y,ro�f o9 _ '� Ini�j _
�, �� �'C/
/ �� ii � �y�s '���
�
.� /�1U � 1 ' nl�l ��(. �=15 ��N — � �n7 fr'�� L�i IaJn�(�
� U
_�;�5 ,��D ��/07 ss��p -f o �r»�_ .
"' "` PRIVATE ONSITE WAST'E TREATMENT county
/,;t,,,_,, ;;;,,
%>i'��o � "��� SYSTEMS SaWyer
`�<_����,yJ�r ( POWTS}
�<'�,_>r_�_�,.;i
INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION 2� -�S�
Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(I)(m)]
Permit Holder's Name: ❑City ❑ Village yf� Town of: State Plan Transaction ID#:
1.✓�11, � Il�l��i� �lUl�.e.v��- �tSS ��-- '-
Insp BM Elev: � BM Description: Parcel Tax No:
��-a � o��ll �a _�i �fo -�-3-s�o�'
TANK INFORMATI N ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic �,� ppa Benchmark pp, p'
Dosing a�-lwr►1 g7.3�
Aeration Bldg. Sewer� �g,6'
Holtling St/Ht Inlet �(g,yS`
TANK SETBACK INFORMATION St/Ht outlet ,�Y `
TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet
AIR INTAKE
Septic � ` 3,�, �� .{-«' NA Dt Bottom
Dosing NA Instaltation
Conto�r
Aeration NA Header/Man.
Holding Dist. Pipe
PUMP 1�IPHON INFORMATION Infiltrative
Su rface
Manufacturer Demand Final Grade oa.0 �
Model Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist.To Well
DISPERSAL CELL INFORMATION
DIMENSIONS W L #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv � Aggregate
INFORMATION P/L Bldg Well Waters � IGP ❑ Chamber Model Number:
❑ AG ❑ 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 ❑ Yes ❑ No l
____----- -
SOIL COVER
__-- ---- -- __— ---- —- - __.
Depth Over Depth Over Depth of Seeded/Sodded Mulched
Cell Center Cell Edges Topsoil _ _ � ❑Yes ❑ No � ❑Yes ❑ N�
COMMENTS: (Include code discrepancies,persons present,etc.)
�=�l�f 91�Y���
7� S,7� t-e���en�'�'" or+�
r—r- -
Plan revision required?�Yes � No � 3 ' d� �-3 �� �c( � �b
. - �
U s e o t h er si de for a d di tiona l in forma tion Da te POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A�OITI�NAL COMMENTS AND SKETCH
SANITAAY PERMIT Nl1MBER: �� -�5�� _
� ,_ ; . , .
.
`�� �.5"� . � _ ; : : _ -_ _.. _ : _- µ- : --- � __.
�l'� : , .
� , /A � . .. . . �_ . � ,. � � _ . _. . . . .. . . � . . � � _ .
v , . , . . .... . . . . ,__ ._ . .. . . ._ . .. . . .
3 6�� � lY4YYw
. Dv'` . . : _ ; _ .
�.n4
�
� �]�,
�s,'
`�� _�1 � ��,('(\ �� " � /6SS
V�
� � �
� t7
��
� , 3� ��� � •
,_ _ _ , a, f, �-.
- �— , �
�h �• _ _ _ � „(� �
'�'�� w��r- -exS�1�, I 5�-�- � �
�,- � S�J" ��N 9'5-13'( ? �(
�
�
����
a��- ��
Du
�
�Pd-
5 AI_E I"=