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Home My WebLink About008-937-20-5322-SAN-2022-336 . ,�:t�^Y"_%�_�;_ Industry Services Division Covnty � ;:;= :�-'�, = 4822 Madison Yards WaY SQw � ,'�'.��=P = IVIadiSon,WI 53705 Sanitary Pcrmit t�umbcr{to be filicd ir.by , ` j P.O.Bo�7162 �� 3 � ' �`—_ ": Madison,WI 53707-71b2 (p . �J\!tSli��`_�i- � Sanita.ry Permit Application State Trensacti-o=umber � In accordance with SPS 383.21(Z),Wis.Adm.Code,submission of this fo�to the appropriate govemmental�uut � is required prior to obtaining a sanitary permiL No(c:App(ication foru�s for stateowned POWTS aze submitted to Project Address(iFdiffetent than�nailing a � the Dcpamncut of Safcty and Profcssional Services.Personai infoanation you provide may be used fvr secondary pu[poses in accorclaacc wit}�thc Pmacy Law•,s_ 15.04(1)(m),Stats. 1.Applicarion[nformation-Pleasc Print�All`�nfor[nation` �` �:' "�� ' � :` ' �`yy(W w Property Owner`,Naine Parcel# -- ---- Ho�rz d Hoirz, �c� - o�e j o �o ------ Property Gk�ner��hiailing Address Property Location iNy�o 3R sT sF ��"��_ City,State Zip Code Phone Number 103� ��7' �ti� �--�Section �� ech � �nN• �'3'3oS � . II.Type of Building(check all that apQ1y) L��" T t� R E or t __ Subdivision Name �l ar2 Famil} D��clling-�umbcrofBedrooms� __._. 3 Block# �ubtic/Commercial-Descnbe Use Ciry of ❑State Ou�ned Dcscrihe Use — CSM Nwnber illage of �'I'ownof L�DSCW4��/ __-_-- — ,�� 7� '� 7/4 III.Type of POtiV1'S Permit:{C6eck cither"New"or"ReplacemenY'and other app�icable online A Gheck one box on"line B:Complete line C if a licable.) -- A �New System �eplacecnent System ❑Other Maiification lo Existing System(explain) �Additional Pretreatment Unit(es�lainl B' f�Holding Tank ❑In-Ground �t-Gradc �Mound Individual Site Desig� Other Type(explain) (conventionai) List Previous Permit Number and Date Lisued C. �❑Renctiv:d Reforc �Revision �ange of Plumber ❑Transfer to New Owner _ L-xpir.Nfun f IV.DispersaUTreatment rlrea and 1'ank Information_- Design l�luw�(��d) � Dcsign S�il Application Rate(�cL��f1 Dispersal Arca R�yuircd(s� Dispersal AreaProposed(sf) System Elevalion ��-- — _ — � Capaciry in Total #of Manuficturer � � a Tank tn;on�at�or. i Gal(ons Gallons Units � ;� U � � I New Tanks Existing Tanks � � p :: � v � ^' m n, U r� v v� �. C:'- a. ...._.}-_...__ '_-- Septic or oitiing Tan- �O rO � ��O�O �� f`4w J /1 Dosing Chambcr � � � � V.Responsibilih Statement-I,the undersigned,assume responsibility for insL•�Ilation of tbe�'POV�'TS sho�sn on-the atiachcd`plans. Plumber's Na�ric{Pnnt) Plumber's StgnaRue :i ti1PRS Number Rusiness Phone Number _l�Auce usrc� ��( �— -��vyf� I 7i5�qy3�.�s�z ['lumber's Ar.dr��Strcc;,Cfty.Sc�te,Zip Codc} .v w ND LsX u� VL.C_ounty/Departmciit Usc Only �- _ 1 Q��, Pecmit Fee -i Date Issued � Isswng Agent Signature �.A��cf�'!,'f�3 ; �Dis;�pprovcd � � � , J�/�� . � ❑Qwner Given Reason for Denial r��' �1 ��I �`� ' ' W��"��'�� Conditions of Approval�Reasons for Disapproval � — � J� M PI i �l � .;' .�-vt `�;/ � �� i �y � _ ,._ .�_ ._.,._ � � � S �i �� i r'V��, .��C# I n 0.3 3-� _.. �� 3 Z�22 , " ; in)�r ir.► '� I � N�,w �� . -------- CS T ��] _ , �- SAINYER COU^�TY o` �K t�1�+1G�nMl�11STR,4i ION Attach m complete plans Cor the system a svbmit to the County only on paper eot ka thaa 8 V2=ll inches io siu ��D� £c- SBD-6398(R.03/21 j NO R�FJNDS AFTER ISSUr OF PERMIT Sawyer County Zoning & Conservation Administration ``„�``1 10610 Main Street, Suite 49 � �R_Cp �� Hayward,Wisconsin 54843 �� AG�I (715)634-8288 �Q� � ��j FAX(715)638-3277 �fA I �-`-'�' '�� v��-w sav✓yercountveo�.ur� / o � �o / E-mail:zonmg.secici�sawvcrcounry�o��.ore � �� Toll Free Courthouse/General Information 1-877fi99-4110 ��,��,;-: -°"�.�= ��i�\oN�� Holding Tank Approval Checklist L Sanitary Cover Sheet Date Stamp � � / �3 /� Parcel ID# O O g- °( 3 ^7- 2 0 -5 3 I � II. Plot Plan �Property Lines �Benchmark BM ♦ / Site Address �C North Arrow � Structure � Scale �Well < 25' to Service Road �Legal Description Nearest Road Intersection Setbacks to: Property Line, Well, Structure, Water bodies, Roads IIt. 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: s k�� 7o S7� 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 l Ol.862(2) and 101.862(3) � � 3" Bedding Material < 1/2 " V. Holding Tank Plans per Component POWTS Manual �Version� SBD-10855-P (R.3/07) �a��'�� '� Owner: ��-.� �- �{nl�� Plumber: / J ^� Application Review Date: � � I 2� /�� POWTS Reviewer: �7 ��%�� Name � �`�S� 1� License# Revised 4/11/2013 CONCRETE HOLDING TANK DESIGN Single Tank Option INDEX AND TITLE SHEET Project Holfz&Holtz Holding Tank Owner Holiz&Holtz LLC Address 14420 83RD ST SE Becker,MN 55308 Legai Description Govt Lot 3-5.20-T.37N-R.9W Township Edgewater County Sawyer Subdivision Name Lot No. 3 Parcel ID Number 8937205310 Plan Transaction ID Number Index and title sheet Page 1 Holding tank specifications Page 2 Site pian Page 3 Maintenance and contingency plan Page 4 Tank Drawing Page 5 Designer Bruce Vitcenda Signature � Phone No. 715-943-2382 License Number M.P.220498 Date 11/21/22 Desgned pursuant to: Holding Tank Component Manual For POWTS(Version 2-6) SBD-1085`✓P(N.03/07)(j�-�,,, '�.1 \ Version 7.0(03/12) Page 1 of 5 HOLDING TANK SPECIFICATIONS 12 Number of bedrooms Non-residential estimated flow(gpd) 6000 0 Minimum holding tank volume required (gal) 7050.0 Proposed holding tank capacity(gal) Skaw Tank Manufacturer 7050 Tank model number SJE Alarm manufacturer 01-H Alarm model number Tank Dimensions and Data Tank Anchor Calculations X for round tank 31050 Ibs Weight of tank and cover 108.3 Liquid depth below i�let invert(in) 1.10 Safety factor 6.0 Maximum de th of soil cover(ft) 47467 Ibs Weight of anchor required 115.0 Height(in) � Outside 47.7 in Soil cover req. for anchor or 174.5 Length (in) Dimensions 11J yd' Concretecounterweight 98.5 Width (in) Only HOLDING TANK CROSS SECTION manhole cover with lockfng device and finished ��ent cap junction � waming label grade box � � — 4"min. 12"min. F—23 in. Manhole and vent locations conduit vent pipe 18"min. � tetherweght - building sewer � service � 12.0 in. inlet blind plug � aiarm on Note: All tank joints, and co seai joints between tank oune� openings and piping are Electrical as per 96.3 in. sealed watertight. All NEC 300 pipe and vent materials and SPS 316 comply with SPS 384. 3 in. beddin9 under tank. Tank is anchored as necessary to negate buoyancy. Project: Holtz 8 Holtr Holding Tank Transaction Number: Page 2 of 5 o w.✓e P Plo„�b�/' rto�tz� Nalrz �cc �✓Roce ��tccudy �HY�+d g3Ad sr sf - �'f�y� sT '�wy4n Dt�� m,✓..fS3oy 7i ��Q+�d� wI S48;S _ y3 �i3b� AL/�,1�$oN4i %� .�oo� T� �� 'rt bo�rcot9 S. �a t . 3�,v � R , qw �at � cs„h �g`71 �k7�q, pqrre( �f aoyl3�a�S3ra Tow,v �d}cwqre! r4'dK'tKa w�p�o : A;s«J wi�e.;w-�ot ° Roa�l [.lS a�t anwe�Yhc/ � T 4uKm'�y mov� a( I �.✓t��G/�/'(/0 �I[�/s��l/S !h(�VeVT Q��4 p��°�eers�;bech� '� yi'/ g� Iva.d' iBP'hu�holtP;Sei * Mov,✓( Syfr�n, ,yiQY bC Put ;,,, h f�t�r�Pe�s�;�r��.t t��y N� �,t� o a ,o� e � g, i� N G g' :. 'o � � � dUil� ��t q/pl 10 SC41( �I 6�fYbw oo't- ;�''..�ltl w a I�— Hwy ��p � HOLDING TANK MANAGEMENT PLAN This Private Onsite Wastewater Treatment System(POWTS)has been designed,and is to be installed and maintained according to SPS 383,Wis.Admin.Code,the Holding Tank Component Manual(SBD-10855-P N.03/07),and the Sawyer County Sanitary Ordinance. 1. This POWTS is designed to accommodate a wastewater flow of 240.0 to 1410.0 gpd. 2. The owner of this POWTS is responsible for system operation and maintenance,including all provisions in the attached Holding Tank Servicing Contract and Maintenance Agreements. 3. Each time the wastewater in the tank reaches 90°k of the tank(s)capaciry or a level of 12"below the inlet (at which time the alarm will activate),the pumper listed in the current Service Contract must be called to empty the tank's contents and dispose of them in accordance with NR 113,Wis.Adm.Code. 4. At each service event,the service provider should visually inspect the condition of the tank,risers and manhole cover(s)and verify that the alarm system functions and manhole locking devices are present. Discrepancies are reported to the owner in a timely manner for coRective action. All corrective actions shall comply with the county sanitary ordinance and SPS 383 and 384 Wis.Adm.Code. 5. All service events or inspections of this POWTS shall be repoKed to the county within 30 days. 6. The owner may not remove any of the wastes from the holding tank(s),or cause such wastes to be removed by any person not authorized to do so under Ch.281,Wis.Statutes.The discharge of wastes tank to the ground surface,including intentional discharges and discharges caused by neglect,constitutes a faiiing POWTS and may result in issuance of correction orders or a citation by the county or state. 7. No one should enter a holding tank for any reason without being in full compliance with OSHA standards for entering a confined space. The atmosphere within these tanks may contain lethal gases,and rescue of a person from the interior of the tank may be difficult or impossible. 8. In the event that this POWTS fails and cannot be repaired,a code compiiant replacement holding tank may be installed in the same location(a new sanitary permit is required for such a replacement). Con- nection to municipal services would also be considered at this time if they are deemed available to the property. 9. If this POWTS is replaced,or its use discontinued,components no longer in use it shall be abandoned in accordance with SPS 383.33 Wis.Adm.Code. 10. If there is a problem with,or question about this installation,the following persons may be contacted: a.Installer......................... A-1 Plumbing Phone: 715-943-2382 b.Service Provider............... Northwest Sanitary Phone: 715-943-2650 c.Co.Zoning or Health Dept. Sawyer County Zoning Phone: 715-634-8288 11. Project: Holtz&Holtr Holding Tank Transaction Number: Page 4 015 NOTE:CROSS SECTION DRAWING DEPICTS EXTENSIONS FLOATING.(PRE-ASSEMBLED) NOTE:LIQUIDDEPTHMEASUREMENTREFLECTS ASSEMBLED TANK DIMENSION. � � 27.00 p7,00 L 24.00-� 24 00� 5ao� �_ � 3.00 3.00-� (- 2.00 INLET g pp I I —�G o�r�Er � os,�W�oSo,»� , � � � �,eo , 41NCHPRESS \BAFFLE(PLASTICAPPROVED I�i FILTERVE� I 905 I SEAC GASKET ANO FASTENED AS APPROVEDJ � � �FLOW CHANNEL � INSTALLEO (8"ABOVE LIQUID 8 I I - (SEE INNERWALL I I WHENPOURED 9"BELOWLIQUIO) �_ DRAWING) I I 3.00-7--�4.00 4.00 I I I I I I � SKA W 5100/5750 � I I � 5130 � �90.5 � �FLOW CHANNEL � � I I - (SEEINNERWALL � � ,� DRAWING) � � �4.00 4.00 I I 3.00-n- \i'x i'L/P EXiEND/NG ENTIRE I I � SKAW 3680/3136 � i 1566/1568 i PERIMETER I I 1OH25 � 90.5 � I I I � I I I I I I I 1 I I I 1 I I I I I I I I I I I\ 1 1 i I FLOW CHANNEL � � FLOW I I_ �SEEINNERWALL I i I I DRAWING) � � � �/ � i i I 1 I 4.� L�__�____��_________________________J 3.0o OUTLET END VIEW OF TANK SECTION VIEW OF TANK AND COVER Model Num6er; Approved for. SEPTIC, HOLDING, PUMP OR GREASE INTERCEPTOR S KAW P RE-CAST Phofte: (715) 967-2277 Weight Inlet Dim. Out/et Dim. Liq. Depth Gal. /In. ax. ap. 26255 105th Street, New Aubum Toll Free: 1-800-924-8625 Wisconsin 54757 Fax: (715) 967-2707 65.03 www.skawprecast.com 31 0501bs. 115" 113" 108.25" 7 058 al. SKAW PRECAST 7050 GALLON SEPTIC TANK PAGE 3 OF 3 TOP VIEW OF TANK (TAPEREDJ s�.oc e�.00 85.00 85.00 � � � � p 72.00 LL 88.50 92.50 9H.50 � � � � m � � iy 163.50 168.50 174.50 ModelNumber. 7050 SKAW PRE-CAST c � Approved for. SEPTIC, HOLDING, PUMP OR GREASE INTERCEPTOR Phone: 715 967-2277 e�g In/et im. Outlet Dim. Liq. Depth ax. ap. 26255 105th Street, New Aubum Toll Free: 1-800-924-8625 Gal./In. Wisconsin 54757 Fax: (715) 967-2707 31,0501bs. 115" 113" 108.25" 65.03 7,058 al. WWWskawprecasLcom 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: Northwest Sanitary, Inc. PO BOX 155 % — � l�� . �� -L �— Radisson, WI 54867 Parcel Identification Number: (l2 Digit Legacy ID) 0 a 8 - � 3 7 - � o - � � / d 1 . The owner agrees to file a copy of this contract with the governmental unit, Sawyer County, which has accepted and recorded with thc Office of the Register of Deeds, the Maintenance A�reement for a Holding Tank required under the Sawyer Co�mty Private Sewage System Grdinance 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) scrviced by the pumper and guarantees to permit the pumper to have access and to enter upon thc property for the purpose of servicing the holding tank(s). The owner agrees to maintain the all-weathcr acecss road or drive so that the pumper can service the holding tank(s) with the pumping equipment. The owner further agees to pay the p�imper for a charges incurred in servicing the l�olding 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 383.5�, Wisconsii� Administrative Code and thc Sawyer County Private Sewagc System Ordinance. The pumper furthcr agrees to include tl�e 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 serviccd; e. The volumes in gallons of the contents pumped fro�n the holding tank for each servicing; 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 tll� eV�l]t Of a C}lfllla� 2i1 t}?:S r�J!1Xr3Cr, t�'lF' OWi?:T' .1�J1'PeS f0 fl�� 1 COr}' C��I7}' C�?3?1DeS t�J t�;1S service contract or a copy of a new service contract with Sawyer County within ten ( ]0) busincss days from the date of change to this service contract. �Wriel''S N3ri1e: �pClIlt� OWIICP'S S1�TriatU1'e: (Only one owner signature required) � � �' � l �- Pumper's Name: (Print) Pumper's Signature: Ronald L Vieceli, owner Northwest Sanitary,lnc %J�"�i � j�I /� (.G �i !QG�E� Pumper's Registration Number: #2389 Rev. 03/26/I 3 �eal E5tate Sawyer County Property Property Status• Current Listing � Today's Date: 10/20/2�22 Created On: 2/6/2007 7:55:16 AM Description Updated: l0/19/2020 Ownership Updated: 8/15/2019 --_______� .____._ ,_.._____:_ _._ _.___�.__.___.._._.u�_..______� ._.. . ..._.�_. _.______.__e_,. _._.____._.. .,_. _ __. . Tax ID: 8806 HOLTZ & HOLTZ BECKER MN 57-008 2-37-09-20-5 05-003- LLC 'P'IN: 000100 LegaGy PIN: 008937205310 Billing Address: Mailing Address: Map 1D: :3.10 HOLTZ & HOLTZ HOLTZ & HOLTZ Municipatity: (008) TOWN OF EDGEWATER LLC LLC STR: S20 T37N R09W 14420 83RD ST SE 14420 83RD ST SE BECKER MN 55308 BECKER MN 55308 Description:. PRT GOVT LOT 3 LOT 3 CSM 28/71 #7199 Recorded Site Address * indicates Private Road _ _ ___._�__.___.__�..__._.__..__�. -.---_._ _._..__ ___._ . ______. Acres: 2.300 . 16446W STATE HWY BIRCHWOOD Lottery 48 54817 Claims: � First Dollar: No Property Updated: 6/28/2021 Zoning: (RR1) Residential/Recreational Assessment _ _ _. _ ____._ _.._..__ _---___... _ _ _ One 2022 Assessment Detail ESN: 430 Code Acres Land Imp. G1- 2,300 15,600 0 Tax Districts Updated: 2/6/2007 RESIDENTIAL __._____.______.........__...__.______.____..___.__._____.__._______..__.._�..___... 1 State of Wisconsin 57 Sawyer County 2-Year 2021 2022 Change 008 Town of Edgewater Comparison 650441 Birchwood School District Land: 15,600 15,600 0.0% �01700 Technical College �mproved: 0 0 0.0% Total: 15,600 15,600 0.0% Recorded Documents Updated: 3/11/2014 _ _ .__ ___---_ ._--.__ _..___ .._.___ . ___------- .,_____ Property History WARRANTY DEED _._._.. ___.._._....._.__..__------_.._ _.__. __ __ _ . Date N/A Recorded: 10/9/2020 427099 LAND CONTRACT Date 419139 Recorded: 8/2/2019 EASEMENT Date 414712 Recorded: 10/4/2018 QUIT CLAIM DEED Date 340376 Recorded: 7/21/2006 CERTIFIED SURVEY MAP _ Date . i II II II�II INIII J IIIII►I III I -USE BLACK INK ONLY- DocI d:��65??v� Tx.:4i�42167 POWTS MAINTENANCE AGREEMENT 442477 For Holding Tanks PAULA CHISSER REGISTER OF DEEDS Owners Name(s)as shown on deed: , SAWYER C�UNTY, WI 11/28/2022 08:47 AM z �l� � � �� RECORQING FEE 30.00 P rcei ldentification u r: (12 Digi[Legacy ID) � Q �-� 3 Z'�` f�-�3 � O PAGES: 2 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. Retum To:Sawyer CountyZoning 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 owne�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, including the following: 1. The owner agrees to contractwith a person who�s 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 govemmental unit within ten(10J 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 hotding tank when pumping reports may indicate the holding tank is not being properly maintained. 3. If the owner fails to have the holding tank properly serviced in response to orders issued by the govemmental unit to prevent or abate a human health hazarct as descritred in Section.254.55, Stats.,the govem�rrentaf unit may enter upon the property and service, or cause the tank to be serviced. Pursuant to Section 14520(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 governmental unit for inspecfion, pumpmg, hauling,or otherwrse servic�ng and mairrta�ning the holdmg tartk trr 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 govemmental unit responsible for the regulation of private sewage systems certifies that either a sa�f absarpfron system that compties with SPS 383,Wis.Rdm. 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 agreemerrt shaft tre bind�ng upon the awner,the he�rs of the owner, and assign�es of the awrTer. The owner shafl submit the agreement to the register of deeds, and the agreement shall be recorded by the register of deeds in a mar�ner which will permit the existence of the agreerrr�nt to be deterrnined by reference ta the prapertywtrere the hofding tank is installed. -Onl one ow er si nature required- � ACKNOWLEDGMENT Owner' ure: - i State of: �I'r�nnF�v-f�,- County of: /11. llt �,x� s Owner' Name (Prin . � � � , � j� Un�c-�-�+na�-� i Subscribed �d sworn to before me on this /� da of /Il�'U��►'�(}e.,!' , 20�� Date: � By(O�nrner's Name): K��f � u �f /v�P� �t�, �� I Notary Public Signature: Drafted by: � Public Notary Name (Print): � rr,m u .:T i�•,.�� '��e (�, or�mission expires on: U/— 3/ aU ol S � YJ.DONNER NOTARY PUBUC-MINNESOTA NY Comm�sion es S Personal informatian you provide m s �n3�8w, 15.04(l}(m}} - Rev.03l26/13 Lot Three(3)as recorded in Volume 28 of Certified Survey Maps,page 71-72,Survey No.7199 as Document No.337869 ,Town of Edgewater,Sawyer County,Wisconsin,being a part of Government Lot 3,Section 20,Township 37 North,Range 9 West. ��'��"�T=-''`�r>_ PRIVATE ONSITE WASTE TREATMENT co�nty >>, ��s � SYSTEMS SaWyer � '�� ( POWTS) \h ` .�ti%i ' "'��'' INSPECTION REPORT sanitary Permit tvo: Safety and Buildings Division (ATTACH TO PERMIT) GENERAL INFORMATION �-� -- 3310 Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(1)(m)] Permit Holde�Nar�e: ❑City ❑ Village Town of: State P�an Trans�ction ID#: 0�'j z '�'�'o I� � �t'� Insp BM Elev: BM Description: Parcel Tax No: ld�-�' �� -s��;h a�-�37•�-0 -53�0 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV Septic Benchmark �G�p,o` Dosing Aeration Bldg. Sewer `36,�` Holding S�v�/ s' � ,� � ,�Ht Inlet �jb.j � TANK SETBACK INFORMATION �I Ht out�et q,�, , � TANK TO P/L WELL BLDG VENT TO ROAD � I�f T N c AIR INTAKE l�.O, Septic NA D� F{`J'p ti'j�' 9$:9' Dosing NA � v-P (o�L�� C�� -�S' Aeration NA Header I Man. Holding �#ts� .}-(�; �` ,{ ` G Dist. Pipe PUMP 1 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 �N � #of Ceils Type of System Distribution Media Manufacturer: SETBACK OHWM of Nav ° Conv ❑ Aggregate INFORMATION P I L Bldg Well Waters � GP ❑ Chamber Model Number: ❑ EZFIow CELL TO ❑ Mound o Other ____--- — — ____-- ----_---- DISTRIBUTION SYSTEM X Pressure Systems Only — -- -- Header I Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipes Length Dia Length Dia Spac � Spacing ❑Yes ❑ No - — SOIL COVER _ _ __ -- Depth Over Depth Over �, Depth of Seeded/Sodded Mulched Cell Center �Cell Edges i Topsoil _ ❑Yes ❑ No ❑Yes ❑ No COMMENTS: (Include code tliscrepancies, persons present, etc.) �;�s��(� ��.�s��3 � ��-� H:-r. - --- - -- 1- Plan revision required?�Yes❑ No � , o� � a y� � _ -� ��_� Use other side for additional information Date POWTS Inspector's Signature Certification Number SBD-6710(R.3/01) AOOITI�NAL COMMENTS ANO SKETCH SANITARY PERMIT NUMBER: a-� ^33� _ , �,��J I � �" � 2��'' � 1 �E L�--��. ±� �s � � d L �- r - � S�` � e�.'r5b � ..a�T . � �� ' � �� ,��p. �►� ve � 3' �'(� �,M• �`�� `� �, �t ' � Y ��y/� /�� 1 f.� 1 O ' 1 � �I��A" IAF�I I .�}--, �l��$ ��LC �"_