HomeMy WebLinkAbout026-176-00-3403-SAN-2023-094 �r�'� U
��� Indus[ry Servicec Di�ision Counry ?
. � , �I� 452�Mad�aun Yards Way I SC�l.v c.�C�- `
-�,\=P = �fl I Madison,R'I Si705 ,i Sanicary Pertnit Nu er(to be filled in I � -
; _ .- (�A q'�\y� � P.O.Box 7302
���n�j� 0 M1ladison,Wi 53707 C I/1�� �
J Vc/ �
Sanitary Permit Application StamTansactionNumber
[n accordance with SPS 3R311(2),Wis.Adm Code,submission of�his fo�m m�he appropna[e povemmrntal unit — �
is rcquircd pnor ro obtaining a sanitary permrc.Notc:Applica�ion iorms for scam-owncd POWTS are submictcd m Project Addrcss(ii different than mailing aaor �
the Department of Safety and Profession�Servires.Pcrsonal infortnation you provide may be used for secondary
purposes in accordance with the Pnvacy Law,s.15.04(i)(m�,Stau. �
I.Application informa[ion-Piease Prin[Ail Informatlon ,S`I �N OYL R U n 2..e I ��
Property Ownrycr's�Vamc I parccl�
��7tC De�e.�o �'�'Ie.�T �-LC OZ(, -I Z(o-OD-3�foD
Prope'(rt�yOwner's ailingAdd/ress PmpenyLocation
T.V� l7X• I T J �
��Gmrtn�—�
Ciry,State �" Zip Code Phone tiumber �
5�h�i""^�� �� ��[C776 5oz-6S6-z8rz —(f"�---f�Section z�
II.Type of Building(check all tha[apply) Loi= T 3q T R �q E or
�Ior2FamilyDwelline-VumberufBedrooms� 34 �� SubdivisionVame p/
Block+l S(�(n$e� lT,
�ublic/Commercial-Describe tise ^
❑City of
�S[a[eOwTed-D scribeL�se CSMNumber illageof
— �rowm oe Sa (A e
III.7'ype of POWTS Permit:(Check either°'Vew"or'°ReplacemenP'and other applicable on line A.Check one box oo line B.Camplete line C i
a licable.
A� �New System ��eplacement Sysrem �Other�1odification[o Existing System(zxplain) �Additional Pretreatmrn[Unit(explain)
I
B' �Flolding Tank �In-Ground �e-Gmde �Mound Individual Sim Desi�n Other Type(explain)
(conventional)
C. �Renewal Betore �Revision Chanee of Plumber �1"ransfer co New Ovmer Lis[Previous Permit Number and Date Lssued
Expiration � �
t
IV.Dispersalllreatment 9rea and Tank Information: —
Desigr Flow(epd) Desi�n Soil Application Ra�e(�pd/s� Dispersal Area Required(s� Uispttsai Area Proposed(s� Sysrem Elevaeion
30� ,'1 � 4��. USZ�p 4�t•'lS
Capaciry in Tocal b af Manuiacr rcr I
Tank Infortnation Crdllons Gallons Unia a� J V _
�Icu'Tank.� ExiatingTank� °" � �
eu' ' v �o ❑.
Scp�ticorHoldingTank -�� _., -j(,O � � �,,� �e5tv--
Dosing Chambcr O �
V.RespOnsibility Statement-i,the undersigned,assume responsibitlty far insmllauon of the POWTS shown an tM1e attac6ed plans.
Plumber's�ame(Pnnt) Plumber'.s Si_ Nrc --';i' ' MP/MPRS�umber Business Phone Number
D (�.� 5�6,.�Lfz .=%�%% _ �S�biz9 ��s-ss8-s�b5
Plum er's Address(Street,Ciry.State.Zip Code) C ,
�o7h nJ s�o✓�e L�.k� �d ��o�-t.e Lafc� c.� l sy s7/
VI.Co epartment tise Only
�App d�- ❑Disapproved Sermit Fee� D/are issued Issuing Agen�Signazure
❑OwmcrGivcnRcazonforDcnial L�' � bl'9'�Q.23
Conditions of Approval/Reasons for Disapproval
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na��n eo�amoi�a pio�:ro�m�,y,o�m��a.�nm�c ro me ca��,o�q o�p.P�.�oc i:::rna�a.�. � s�all�MbA,'iSfRATION
SBD-6398(R.02/22) NO R�FUNDS AFTER
ISSUEOPPERMIT �.hqra: `�� 'G����
*t�-j�L(,,` paven+�- a��L' %1�
` ""`'i PRIVATE ONSITE WASTE TREATMENT co�nty
`��� \ SYSTEMS
J ' °$ - Sawyer
-.� �$ .� ( POWTS)
'�,k`f_�_-i�=i`
�` INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �� - ���
Personal infonnation 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#:
��,� �e.v. L L C._ �a��Q ��C-�- �
Insp BM Elev: BM Description: Parcel Tax No:
�oo.o � n►4; � ��b�,� �„ s .5��� o� 1�"�a k �a-�- c7��oo-3Y��
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS EL.EV
Septic �,,,,;e�- �S'� Benchmark ��,,o�
Dosing
Aeration Bldg. Sewer Q7,,L �
Holding St/Ht Inlet y �,� '
TANK SETBACK INFORMATION St/Ht Outlet � _3s'
TANK TO P/L WELL BLDG VENT TO ROAD Dt Inlet
AIR INTAKE
Septic .f-,2S- Jf '�� �.-7 � NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header I Man. � .o '
Holding Dist. Pipe
PUMP 151PHON INFORMATION Infiltrative �
Surface 4S �
Manufacturer Demand Final Grade
Model Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist.To Well
DISPERSAL CELL INFOR ATION
DIMENSIONS �N 3 L c�y YY #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate ��( I
P I L Bldg Well ❑ IGP y� Chamber �'
INFORMATION Waters � AG ❑ EZFIow Model Number:
CELL TO �f S' ('S' �/ ❑ Mound o Other �4 �
-- ---- - -- __ -------- - -----
-- -_ -
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
- - - — — - -�
SOIL COVER
-- --- ---- —
De th Over De th Over I De th of Seeded I Sodded Mulched
P P P
Cell Center Cell Edges I Topsoil _ __ ❑Yes ❑ No ❑Yes ❑ M�
COMMENTS: (Include code discrepancies, persons present, etc.)
����i�.�' ��g 12 3
�
Plan revision required?❑ Yes 0 No � p3 0 �� � I�_ ' _ ll �4 � �� �
� �
Use other side for atlditional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A��ITIONAL COMMENTS ANO SKETCH
SANITAAY PEAMIT NUMBEA: ��-o�y__
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