HomeMy WebLinkAbout010-941-21-2138-SAN-2023-097 —a�3� o�; �_-
� \ ' Industry Services DrviSon ,C unry �7
,�, _ /�� _ 4S>2 Mad�no i Yards W ay S4 W�C l^ �
\SP = �(},j 1 �,, Madison,RTSi705 ',S�itaryPerrii:h� ber(tobefilledint �
E IQ/ q1�/ P.0 Box'30� i
���'� $��' \ Madison,WI53i07 I ����� � "�
�r.nAr,
' 'S[ate Tra�sactioc Number O
Sanitary Permit Application i � �
In accordance with SPS i8311(2),Wis.Adm.Code,submic ion of[his fortn to the appropnate govemmental unit� �
is rcquircd pr.or m obtaining a san;ury pcm:ic.Vo[c:,4pplicz[ion forms for stam-owncd POlB?S are submittcc ro;Projec[Addr:ss(ii differmt than mailin„ . ,
[he Depz^[men[ofSxfety ar:L Professio��Services.Personai infoma:ion you provide may 6e u.�ed for secondary i /
purposes in accordance wirh the Pnvary Law,s.15.04(1)(m),Stats. �11 r1 W n �
I.Application information-Please Prin[All Information I ��� O Vl S4w C r F
Proporcy Owncr's Namc I Parccl x �3�i(
a�� ���d LLC �� 0�6—�141—Z�—
Pmperty0v+ner'sMailingAddress '��Pmpertytocation
I OSlol f� ` �,e� �}';L� 2� ,,...�t� •
Ciry,State Zio Code i�Phone Number ^ �
�'�4 W4v'a. �,C.�( I. �j�{�'l{3 I(�OZ-40Z- b34� I_�'/.,N� '/•,Seccion z�
II.Type of Bnilding(check all that apply) Coc= ;? �j N R � l H o�_
�Ior?FamilyDwellin�-tiumberofBedrooms_� 3 �SubdivisionName
Block a
�ubliciCommercia!-DescnbeL'se �_
'..,��Ciry of
�SmmOwned-DescribeL'se CS'.vlVumber iilageo:
V.ISP•
Z26 3�� �Toemof '�'ct�-(war�
iII.Type of POWTS Permit:(Check either"New^or`ReplacemenY'and other appticabie on line A.Check one boz oo line B.CompYete line C i
a ticable.
A' �NewSystem ��:placementSystem ��[herModificationroExistingSystem(explain) i�AdditionalPretreatmrntUni[(explain)
B' ❑Fiolding Tank ��In-Ground ��^.�-Grade �Mound tndividual Siee Design OthaType(eaplain)
I (wnver.tional)
C. �Rmewal Before i❑Revision pChznge of Plum6er ❑Transfer to Vew Owner "�PTecious Prrmit�end Da[e Lcsued
Expimtion
IV.DispersaUTreatment Area and Tank Informaflon: �E, -
Desi�F'ow(;pd) I Desi�n Soil Appli<a:iun Raee(gpe�s� j Dispersai A;ea Required(s� ;Disoersal Arez Proposed(s� Sys[em Etwa[ion
450 •�1 i 643 i b9z Gs,zs
Caoaciry in i To•al �of Manutacnarer I
Tankinfonnanon ���on �i Gallons �' linirs I I`� I _ � = -- =
ticwTank i Exi.atin�Tankc � u "
�U i v: �
cpd orHoldingTank `o oO i � � P.,�tser I I
W
Dosing ChaTbn I i I � � O �
V.RespOnsibility Statement-I,the undersigned,assvme responaib�ity for insrallation of the POWTS shown on�tAe attached phna
Plumber's Vame(Pnnc) :nbe aur �>.fPMIPRS t�umber 'Baciness Phone NumbR
(�o(� Lc�b�.�re IZZ(oz,�g i"7�5-644-a93�
Plumber's Address(Sttee4 C1ity.Stau.Zip Code)
�4.7�'�'� ll.� ST.. 1`C. „ 4 I,t74r� lP7� S�g4�
VI.Connry/Departmentl:se Only
J�Ap � ' O Disapproved �.`e it Fee �Date issued issuing Agen�Sign
� �Owner Givrn Rcason for Dcnial `�'� � � �O�l �w
Conditions of 'pp�dJaGReazons for Disapproval
�:��GI�,� ���-a3 _ � � ��__ -- �����
a3o38 1f\1 �
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CS� �� — ��� l�'�7 _ - � � __
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pttnch ro camplere pians for ehe system and submit ro cM1e Counn�onh on paper notless than 8 in •`�
SBD-6398(R.02/22) NO R�FUNDS AFTER
ISSUE O^PEflMIT ��,��I'_ 44�7 r
'��11�^' �arer�t'� /,Z..�S /
t�"'""T'-;F^r; pRIVATE ONSITE WASTE TREATMENT cou�ty
��� �' SYSTEMS
��� S awyer
�-,,�SPs �' ( POWTS)
� N � < y�,
' "� INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION a�—0��
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 Transactio�ID#:
l.� ��q�r-� .----
Insp BM Elev: BM Description: Parcel Tax No:
(c�0.a ' ��u� a-��o�,,, � ��„� w•s�� �� 1940ak O Ip.-9`f'(�-o?�� �13$
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic W �e�- �p Benchmark �po.o '
Dosing
Aeration Bldg. Sewer �j7 Y$"�
Holding St/Ht Inlet �t7,o3 �
TANK SETBACK INFORMATION St/Ht Outlet q(.,,g 3'
TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet
AIR INTAKE
Septic ��o` +Z � � .�-g ' NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man. 96',d '
Holding Dist. Pipe
PUMP 1 SIPHON INFORMATION Infiltrative q�`a �
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 3 � L $ g #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate � ,
INFORMATION P/L Bldg Well Waters °� G � Chamber Model Number:
❑ EZFIow
CELL TO la -}�01-�" +jb /�/ ❑ Mound � Other Q +
Y
--- —- --— --- -------- -. ---
DISTRIBUTION SYSTEM X Pressure Systems Only
Header/Manifold Distribution Pipe(s) 'I X Hole Size X Hole Observation Pipes �
Length Dia 1 Length Dia Spac Spacing ❑Yes ❑ No �
--- -_--- ----- - -- I ---- ---- — -----
SOIL COVER
_------ ;
Depth Over Depth Over Depth of Seeded I Sodded Mulched
Cell Center �Cell Edges '� Topsoil ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present,etc.)
�,��f�,,,{ g���23
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Plan revision required?❑Yes � No I�? v7 � � . � �_ �
Use other side for atlditional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AOOITIONAL COMMENTS AND SKETCH
SANITARY PEAMIT NUMBER: oZ_3'��.__
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