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Home My WebLink About026-938-07-5621-SAN-2023-041 - Department of Safety c0°"� Uj 9 & Professional Services, S `'' �� S Sanitary Permit Number(to be filled in b � �S Industry Services Division �9 �3(� � lr.D W Sanitary Permit Application State Transaction Number G �� In accordance with SPS 38321(2),Wis.Adm.Code,submission ofthis form to the appropriate governmental unit ,,,� is required prior[o obtaining a sanitary permit.Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailin€ r. the Department of Safety and Professional Services.Personal information you provide may be used for secondary � �� purposes in accordance with the Privacy Law_s. 15.04(1)(m),Stats. �,� 3�� Nti I.Application Information—Please Print All Information Property Owner�s Name D Parcel# 1 �� h o26 . �3g� o�.��2) Property Owner's Mailing Address Propertx�Location 313o Go.n,� I�r�n<<o� �� co�� City,State Zip Code Phone Number � � 50:+-�-� {�q/l b✓l �� ---t��"•—�s` Scction IL Type of Building(check all that apply) Lot# T�N R d E or 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 �,��37 �?y 1 �-ow�,of s�.,� Iw�e III.Type of POWTS 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. �� w System �Replacement System ❑ Other Moditication to Existing System(explain) � Additional Pretreatment Unit(explain) B' olding Tank ❑ In-Ground ❑ At-Grade � Mound ❑ Individual Site Design ❑ Other Type(explain) (conventional) ,--, List Previous Permit Number and Date Issued C. ❑ Renewal Before �� Revision Change of Plumber � Transfer to New Owner Expiration � � �j � � � IV.Dispersal/Treatment Area and Tank Information: Design Flow(gpd) Design Soil Application Rate(gpd/s� Dispersal Area Required(s� Dispersal Area Proposed(sfl System Elevation 30� � N N� — Capacity in Total #of Manufacturer Tank Information Gallons Gallons Units � � o � � U New Tanks Existing Tanks '` o ;; ` Y � � `c� a U ✓: � � r-:- C7 G. Septic or Holding Ta�ik 0 d(� Z(�(j �,/�tStr 1 Dosing Chamber V.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. Plumber�s Name(Print) Plumber's Signatur� M{'/MPRS Number Business Phone Number �D �... S��N'z__ �SI6�z ��,�-s�s��-�s-9�� Plumber's Ad ress(Street,Ciry,State.7ip Code) , ?�16,1/ s.�,,,,�,� ,.c..� r� 5.�,,�u.- ��,� �,.'r ,s�f p 7� VI.Coun /Department Use Only �Apsc� u�� ❑Disapproved Permit Fee Date Issued Issuing Agent Signature ❑Owner Given Reason for Denial $ L�'� �� '" �� r`�,�"'�'`Z.0 �.``1-�,�2��-, Conditions of Approval/Reasons for Disapproval �� a�_ S � - �= .�.�:..�:. � ► k � � r �� ' �rrr► � -�u � �hk# '° MAY 0 1 2Q23 O � ✓ \ 1�G �S'�lfit ' �' � TW-�-'�--�"� --- -1 � N � , ,� SAVV�r'�R C��..�,,:�::.--, �ONING AGM�r��s��s�:i��,-::,; Attach to complete plans for the system and submit to the County only on paper not less than S ln x 11 inches in size �--7--�� SBD-6398(R.03/22) �Q�i��UNDS AFTER I�U�OF PEFcMIT Sawyer County Zoning & Conservation Administration �� 10610 Main Street, Suite 49 � ER cp 1� Hayward,Wisconsin 54843 '� -'� ��'��i �� (715)634-82R8 � FAX(715)638-3277 i Q�/ ��I I�' „' _� --_ ��/ wwwsaw ercounlvttov.org � E-mail:sanitarian a'sawvercoun�ov.org �I o =� ` �°� Toll Free Courthouse/General Information 1-877-699-4110 ,� �`' Jry/�� j 1`o'N`� Holding Tank Approval Checklist I. Sanitary Cover Sheet: Date Stamp DS / � � l 023 Parcel ID# �� (o -� 3�- v � - S� a � II. Plot Plan: 1� Property Lines �Benchmark BM ♦ p(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 ($30 to ROD) N. Holding Tank Specifications: � Tank Cross-Section: Manufacturer: Wi�a�2� Gallons: �,d°� �Tank Anchor Calculations [SPS 383.43 (8) (g)] Locking device, chains/locks �Alarm, electrical per SPS 383.43 (8) (e) �3" Bedding Material < 1/2 " V. POWTS Component Manual Reference: D� Holding Tank Version 2.1 (May 2022-2027) Owner: J�� -I�+�'1� Plumber: _�_,� SL��'Z Application Review Date: �I � �3 POWTS Reviewer: ` Name 6 9��(� Rev. 4/20/2023 Credential# PAGE 1 OF 4 Holding Tank Plan Index & Cover Sheet Component Manua/Design Reierences: Holding Tank Version 2.1 (May 2022-2027) 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): ��-�.� ��'1 nu� Phone: - - Owner Address: 3130 S Lar,El o-�,-.}h;co.� �� 5�..� f�oc� w� Zip: ,S'18 7y � , Project Address: L�3Cy Ill K^��.wc..y �,� Govt.Lot: � 1/4 of 1/4,Section b� ,T �g N-R 0�1 E�or W,� Township: ��c� �c��L� County: ��.INv-el' Project Parcel ID#: b Z� '9 3�- ��s- 6 2 I Designer Information Designer Name: 'U �-�. ✓G��T�- Phone: �Y - S� - �yG Designer Address: �7�U �-' � �'� Zip: ��/��_ E-mail: �y��.�c�o� �15� 9n",i�,Gen� « � ��r��, � , . � . License Number; �S��2 �1 Remarks: Signature: Date: `� �Z� �2 3 Origi I � natur ed on each submitted copy. CHECK BO%AS APPLICABLE CHECK BOX AS APPLICABLE. � SOIL EVALUATION o Scale: 140 ao' so 80 �YSTEM PAGE 2 OF SITE MAP PLOT PLAN �p PROJECT NAME ��, DESIGN FLOW: � O v cPo Attach design flow calculations for commercial plans. PROJEGT ADDRESS: �I 7GQ N ��"��"'�� n Pipe Matenal/ASTM S[a dard(Tables 384303&384.30-SJ ( N SanitarySewer S� �Q / BM SYmbd: � BM Elevation� I O O FT �7- ( f Porce Main'. / BM Descnplion'. l f�1 9�� v I�V —'r IMPORTANT: Intliwte north ty Slope Gretlieirt(°h) Well Sjmbd(Rapplicable)'. Q drawing an artow Show ground elevation contours at suitable intervals. of Testetl Area: on Me approprite line. �-- �� S�S ��,tiv �� _l�--�— � ��,/�� a� �,Je��n� 7� �� <<s��- a � �j��'R'�� W�� pOD ` I 5e� 5�� 2 � � w�l( `I��I' S� � � � � � � +� I �Ylw{� SL��I �� ) ��5 �Srdlty � � l � � 3 �36yn� � � I H-�►„wy �n I � i [ � � ��.a-I��F� �� - i PAGE30F4 HOLDING TANK SPECIFICATIONS (No Scale) Weatherproof 12" Min. or 2.0 ft above Junction and Approved Established Flood Elevation Alartn Box Venl Cap «YP�� Electncal must comply with 1 Approved Locking Manhole SPS 316 and NEC 300 4"B Vent Pipe � with Waming Label Attached �Conduit �10kfrom (typiral) 4" Min. or2Dftabove Building I Established Flood Elevation ` I ' � (�YPical) �' �Airtight Seal " e Finished Grade 18" Min. �tYPiral) . .:a � � 8 ° a e ' Inlet Inletlnvert fWatertight Approved JoinLs with P��9 Approved Pipe 3 ft onto � Max. 12"or 90% of total volume Solid Ground if more than one tank a ' Alarm-0n a HOLDING TANK VOLUME = Z-��b gal e a ' . d . . . a . . . . . . . e . 3"Approved Bedding Material Beneath Tank TANK MANUFACTURER: W� tSe� 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.wt] x 1.5 Ballast Weight = [( cu.ft. x 62.4 Ibs/cu.ft) - Ibs] x 1 .5 = Ibs PAGE 4 OF 4 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 pertormed by a registered POWTS Maintainer in accordance with SPS 383.52 (3), Wisc. Admin. Code. Estimated Daily Wastewater Flow = 3 � gpd 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 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 levei of one foot below the inlet invert of the tank(s). Disposal of contents shall be pursuant to 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 maifunction to: � � � �� S- S'.Sg 'Sf°5� Name of individual or company: �� y `h. ��"' Z- Phone: _ Local government unit: �'��( {� �"`^ Z�ti'^� Phone: �� " G3y'�Z�� U Localgovernmentunitaddress: ��+ �'la�� °``�"N� �� ' ZIP: S� � 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. Continaencv Plan In the event that any failed 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. WSLP2000 HOLDING ,ea" TANK SPECIFICATIONS � � � o o a DIMENSIONS: a � WALL: 3" � o — BOTfOM: 5" a a _ _ _ _ _ _ _ _ _ _ _ _ _ _ COVER: 6" 0 MANHOLE: 24" I.D. PRECAST CONCRETE RISER � � I I� HEIGHT: 46" O.D. ii - II 4" CAST-A-SEAL il ` LENGTH: 184" O.D. `� WIDTH: 102" O.D. � � � I� BELOW INLET: 34" O.D. w 024" LI�UID LEVEL: 29' � w a � ' o I WEIGHT: TANK - BOTTOM 14,530 LBS. � � � � I �YP � �i COVER 9,300 LBS. ' �I I� � INLET: 3 0 0 '.I I 4' CAST-A-SEAL BOOT OR EQUAL m o � o � _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ INLET BAFFLE: � a J — �� NASCONSIN, SEE DETAIL �10 0 0 � TOP VIEW (OTHER STATES SEE CHAR� W N n LIOUID CAPACITY: 69.77 GAL/IN � � HOLDING TANK: � � OUTLET HOLE PLUGGED �. U � AC1l1AL CAPACITY: 2,020 GALLONS C � � LOADING DESIGN: 8' 0" UNSATURATED SOIL � Q p� w � � TANK CAN BE USED AS: � � � HOL�ING/ PUMP M W � i COVER: MIX DESIGN �8 (NO FIBER) y 3 a VENTED LID TANK: MIX DESIGN #9 (SMALL FlBER) W � � � CUSTOMIZED TANKS: � � N Q � FOR CUSTOM TANKS CONTACT WIESER CONCRETE � � Q w 3 � ., .. . : , �.. .- . ... . . ... .. � ., �� . WLET — c� _ _ � Z J � 9 � a b" � - t: o z � M N a "� O f �� — �_,T -.-- _._ _ —, �� N U H DRAWINGS SUBMITTED � N '� FOR APPROVAL SIDE VIEW APPROVED BV: SHEET N0. APPROVAL DATE: TANKS ARE MANUFACiURED TO MEET OR EXCEED ASTM C-1227 REQUIREMENTS PRODUCTS NEEDED BY: / F ,� HOLDING TANK SERVICING CONTRACT ContractDate: y /�/ Zot ; This contract is made between the Aolding Tank Owner and the Pumper. Holding Tank Owner's Name: Pumper's Name: �w-� �-I ��h� � S�.o� - -�� .. Parcel Identitication Number: (12DigitLegacyID) �Z�-��- p 2-,��L l. 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[he Sawyer County Private Sewage System Ordinance for tUe issuance of a Sanitary Permit for the installation of a holding tank(s). 2. The owner agrees ro l�ave flie holding tank(s) serviced 6y the pumper and guarantees to permit the pumper to have access and to enter upon the properry for the purpose of servicing the holding tank(s). The owner aa ees to maintain the all-weather access road or drive so that the pumper can service the holding tank(s)witli the pumping equipment. The owner fiuther agrees to pay the pumper for charges incurred in servicing the holding tank(s)as mutually ageed upon by the owner and pumper. 3. The pumper agrees to submit to the Govemmental Unit,Sawyer Counry, a report for the servicing of the holding tank(s)as required under SPS 383.55,Wisconsin Adminis[rative Code and tlie Sawyer County Private Sewage System Ordinance. The ptUnper further agrees to include die fol(owing in the report: a. The name and address of the person responsible for servicing die holding tank; b. The name of the owner of the l�olding 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 Ihe holding tank for each servicing; f. The disposal sites to wliich the caitents 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 agrees to file a copy of any changes to this service contract or a copy of a new service contract witll Sawyer County within ten(10) business days from the date of change to this service contract. Owner'SN8IIIC: �PpRT� �W110T'S $I 3 0: (Onl�onemvnersignaturcrequired) �v� r��L ll�A j�_�.�� ,�� Pmnper's Name: (Print) um er' Si re: c �� .� Pumper's Registration Number: 61812j Rev.03/26/t3 i i�� I li �llllll� �l I � I 1111111 I l ll l.l D��I :8Q69�3'{ - USE BLACK INK ONLY - i x :4044819 POWTS MAINTENANCE AGREEMENT 444285 PAULA CHISSER �or Holding Tanks REGISTER OF DEEDS SAWYER COUNTY, WI Owners Name(s) as shovm on deed: / ) '/ 05/O1/2(}23 02:0$ PM ..J vl /`j�i��',,.r q� .S�.O-r,!h •SLJ'�NSGr�J/��i, � ��,� _ RECORDING FEE 3fl.fl0 ..► - ,� Parcel Idenf � tion Number. . (12 Digit Legacy ID) Q �� - � � � - �7 � _��L PAGES: � Legal Description of Property: - 5EE ATTACHED SHEET - We acknowiedge that application is being made for the instaUation of a holding tank(s)on the property described on the attached sheet. Retum To: Sawyer County Zoning and Conservation Admintstration 10610 Main Sf, 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 hoiding 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: i. The owner agrees to contract with a person who is ticensed under Ch_ NR 113, Wis. Adm. Code, except as provided by Section 281.48 (3) (d), Stats., to have the holding tank praperty serviced and to file a copy of the service contract with the govemmental 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 (10) business days from the date of change to fhe 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 govemmental 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 shafl submit the repo�t to the govemmental unit. The govemmental unit may enter upon the property to investigate the condition of the holding 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 hazard as described in Section_ 254.59, Stats., the governmentai unit may enter upon the property and service, or cause the tank to be serviced. Pursuant to Section 145.20(4) Wis_ Stats., a govemmental unit may assess the owner of a private sewage system for costs related to the pumping of a septic or holdirtg tank. The charges will be assessed as prescribed by Sectian 66.0703, stats. The owner agrees to pay all charges and cost incurred by the govemmental 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 govemmental unit responsible for the regulation of private sewage systems certifies that either a soil absorption system that complies with SP5 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 shall be binding upon the owner, the heirs oF the owner, and assignees of the owner. The owner shall submit the agreement to the register of deeds, and the agreement shall be recorded by the register of deeds in a manner which wiU p e e�tistence of the agreement to be determined by reference to the property where the holding tank is installed. one n si nature re uired - ACKNOWLEDGMENT O ,Wr�t'.s- �g re: � � ; % State of: � .S � C ti ��•t, ' C '�-- 4�+rn am rint : �� i�� County of: _ �li A.� (� �, � v<� � ��/ �� `\��\��O 31 Sii,�ubs ribed and swo to befqre me on this �` 5 ^ • . '_� -�_day of :.t l , 2 v� _3 Da e: . � �.' d .�Bj'r�Owner's Name): �,i� ( �„v �/— �'G ^ z n � _ � • n 2 ; �ary Public Signature: � Drafted by:�, � � % •. ' �'�ilic Notary Name (Print): �.• ,� ?�k • . �1 bd . � ��\ commission expires on: � - .� ''�i��NtJN,��\\��. Personal informaBon you provide may be used fw secondary purposes [Privacy Law, § 15.04 p) {m)] Rev. 03�26/13 � That part of Government Lot Six(6), Section Seven (7), Township Thirty-eight (38)North, Range Nine (9) West,Town of Sand Lake, Sawyer Counry, Wisconsin, more particularly described as Lots One(1), and Two(2)of Certified Survey Map No. 74] filed in Volume Four(4),Page 137 as Document No. 154507 on March 15, 1976. 5/7�23,17:16 AM Real Estate Sawyer County Property Listing Property Status: Current Today's Date: 5/1/2023 Created On: 2/6/2007 7:55:47 AM B Description Updated: 6/8/2020 B Ownership Updated: 6/8/2020 _ _ _ Tax ID: 27751 PAUL S HLINA SOUTH RANGE PIN: 57-026-2-38-09-07-5 OS-006- WI 000210 JUDITH SWANSON-HLINA SOUTH RANGE Legacy PIN: 026938075621 W� Map ID: :6.21 WILLIAM JAMES OSWEGO IL Municipality: (026) TOWN OF SAND LAKE SWANSON STR: S07 T38N R09W ESTHER E LEE OSWEGO IL Description: PRT GOVT LOT 6 LOTS I-2 CSM 4/l37 #741 Billing Address: Mailing Address: Recorded Acres: 3.660 PAUL S HLINA PAUL S HLINA Lottery Claims: 0 3130 S CAMP 3130 S CAMP First Dollar. Yes AMNICON RD AMNICON RD Waterbody: Sissabagama Lake SOUTH RANGE WI SOUTH RANGE Wf Zoniog: (RR1) Residential/Recreational 54874 54874 One ESN: 423 � Site Address * indicates Private Road 4364N HATHAWAY LN STONE LAKE B Tax Districts Updated: 2/6/2007 54876 _ _ _ _ 1 State of Wisconsin 57 Sawyer County B Property Assessment Updated: 9/28/2017 026 Town of Sand Lake 2023 Assessment Detail 572478 Hayward Community School Code Acres Land Imp. District Gl-RESIDENTIAL 3.660 299,100 7,300 001700 Technical College 2-Year Comparison 2022 2023 Change B Recorded Land: 299,100 299,100 0.0% Doc�ments Updated: ll/8/2019 Improved: 7,300 7,300 0.0% B TRUSTEES DEED Total: 306,400 306,400 0.0% Date 388780 Recorded: 12/23/2013 B Property History B SCRIVENERS AFFIDAVIT N/A Date 300607 Recorded: 6/3/2002 B QUIT CLAIM DEED Date 255864 LC583/313 Recorded: 8/6/1996 SCRAFF805/920 https:�/sawyercowi.wgxtreme.com/ieProxy?url=http://tas.sawyercountygov.org/ACCESS/REAU°,20ESTATE/listing.asp?pid=27751&ui=0 Page 1 of 2 � r �, � ' !� .� �� _.. ` Y v '+1C� � ^� ,��!�� . � +,pR. � , �.f ;°� ,, �� z '�,, � � z/1S /�;'r�� : � �� :�+ .. f .}/f rf' q�j��?.{ �. ',"�' . �' ..a. . �� 1 �i •I � f ��I : � �'+'Vi � � � �[: ` R �� +4-'� -' . r � f;.� � � �� 3�'''� ,�' �� . � � - 1 . $�� ! �/.�� ' ,( �! � � �."� • �Y�s• �i .�� i .E+r-,r, { ,. � , '.�� .. . �..: .�,�,r � ,� .-L •� �i � ' 't ' .��la�' � ' •i� 7 , .P. 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S°4�� Insp BM Elev: BM Description: Parcel Tax No: � �' � � �,,��-,��,,, a�-b— �3�--�� 5��-� o O� �( s c�c , TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV Septic Benchmark �o D,o� Dosing Aeration Bldg. Sewer ��.y� Hoiding w�2y�— ��cvp�� St 1 Ht Inlet �( $ , TANK SETBACK INFORMATION St I Ht Outlet TANK TO P/L WELL BLDG VENT TO ROAD Dt Inlet AIR INTAKE Septic NA Dt Bottom Dosing NA Installation Contour Aeration NA Header I Man. Holding �30 �1 �'� r-S �� Dist. Pipe PUMP 1 SIPHON INFORMATION Infiitrative 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 L #of Cells Type of System Distribution Media Manufacturer: SETBACK OHWM of Nav ° Conv o Aggregate INFORMATION P I L Bltlg Well Waters � GP ❑ Chamber Model Number: ❑ EZFIow CELL TO ❑ Mound o Other --- -- -- — — - DISTRIBUTION SYSTEM X Pressure Systems Oniy - - -- Header/Manifold Distribution Pipe(s) X Hole Size X Hole Observation Pipas Length Dia� Length Dia Spac Spacing ❑Yes ❑ No� SOIL COVER - —T -- — -- - — ( Depth Over Depth Over Depth of Seeded/Sodtled Mulched Cell Center Tell Edges I Topsoil 1 ❑Yes ❑ No ❑Yes ❑ No COMMENTS: (Include code discrepancies, persons present,etc.) ��..5�� `� �� 2 3 � ' l `I � ��_ J � Plan revision required?�Yes 0 No �,,,.,��9. 2y " � _ '' �`� ��(�' � __ Use other side for additional information Date POWTS Inspector's Signature Certification Number SBD-6710(R.3/01) A�OITIONAL C�MMENTS AN� SKETCH SANITAAY PERMIT NUMBEA _______�3'-�`� - --- _-�__ � ��s . 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