The URL can be used to link to this page

Home My WebLink About010-941-21-2139-SAN-2023-098 � � �'�� ri �� . � Indus[ry Se -ces Die�ision oun � �� I, 4523 Mad o "ard`Way ' 4W t Y �SPS = �2�ly� �rad�so�,w��o. sz,�c�rvP��:r�b«�mb�Fue F� .— \ /�� d� ,,., P.0 Box'302 , ��'OI � �x�� d1� �Iadison,Wi 53 i07 � Sanit•d1•y Pet.mlt AppllCati�n I ScareTmnsacrionNumber �'^ In accordance with SPS 3R311(2),Wis.Adm.Code,submission of[his fortn ro the appropnate goeemmrntal unit� � is requ:red pr.or m obtaining a unitary pertr.it,Noec:.4pplica�icn fortns for stam-owned POW?'S are submi[ted W Project Address(ii differrnt than rt the Depamnen[ofSafery and Profession�Services.Pcrsonai infomation you provide may be used for secondary purposes in a^.cordar:ce with[he Privac,v Law,s.15.04�1)(m),Stass. J�2 n 1 I.Application information-Please Print AII InformaHon I��p��O Vl S4w <r t p Property Owncr's Vamc �� A�� a L�c � oro_44�_zi �_ '.� Property Ov.mer's Mailing Address j Property Loca�ion I DS(ol 1� ` �,e� �':l� 2� �c�,�.co� � C�ry.State Zip Code Phone'Jumber I-E-� w4v� �( S�{843 IboZ.-4oz_ 6391 �.1E,, NcJ ��,s��an .�.� II.Type of Bnilding(check all that appiy) Loe� I,T �'� N R d l E o N _ �Ior2FamilyDwe:ling-NumberofBedmoms�_ �"� �,SubdivisionName Block� �ublidCommerefa!-DescnbeUse ^_ � I❑Ciry of �StamOw-�ed-DescribeL'se CSMNumber �. iliageof CS�"� IS/Z26 )7Y3 �ro�.or �'a�warc� iII.Type ofPOWTS Permit:(Check either"Yew"or"ReptacemenY'and ot6er applicable on line A.Check one box on line B.Comphte line C i a licable. A� �.'ewSys[erc i�epl2cementSysrem I�therModificationtoExis[in�System(explain) I❑Additio�alPreVeatmentUnit(explain) I � I B' �❑Elolding Tank �In-Grocnd i❑A�-Grede ❑Mound �Individual Site Duign Othtt Type(explain) (conventional) C. '❑Renewai Before �Rrvision hanee ofPiumber ��I'ransfer ro New Owner ��t Pre ious Pmnit Num6er and Date Lcsued Expiration I N.DispersaVTreatment Area and Tank Information: .S—q4' Desie,p Flow(epd) �Desi�n—So1il Applicaiion Ra[e(gpd�'st) ,Disp/rsa�i'Area Required(sf? i Dispersal A ce Proposed(s� System Elevation �{'SD • 1 � �p�3 6�.Z 43•S' Capaciry in Total �of ManufaeNrer Txr�k informarion Gallons Gallons linirs - = NrwTankc Exi.ctingTankx I ?� V� - � aU i'w H '�U d cOd orHoldingTank �� I � W L2SLcY, � Dosing Chambc � � V.RespOnsibility Statemen[-i,the underaigned,asmme responsibility for instn0atioo ofthe POWTS�showo on the attached pians. Piumber's Yame(Pnn.) . � *.fPMPRS rumber i Busivess Phone Number �o� l_.c�bG.rre � !ZL�7a 8 '1�5-64�-a43� Piumber's Address(Strce4 City.State.Zip Code) �4�44 l� S-E_ �c�. `T`i � tv4r d te7( S'-E$4�j VI.CoonN/Departnent Cse Only � . �Ap v� ❑Disapprovcd i p��t Fee Date issuec ; Issuing Agen� ignanue 'S /J�y1 f � � O Owncr Givcn Rcazon ror Dcnial -(,V�•� � ` Conditions of Approval�Reuons for DisapproJal ��GI�� ^. �_�o_�3 � ��,��,��(. i'tlr�i� - � ZJ I� as o39 U �sT 23-�S l ) ��4 JUN 1 2 2023 Attac6meompleaplanslortAesyshmandsubmit[otheCaunh�on ��`- ,Q��NTY ty on paper not less tM1an 8 v±x-��N I SBD-6398(R.02/?2) NO R�FUhDS AFTER I�UE OF PERMIT �k;��I:�y�17 ? �,fi��- ,�a.�;,�: /z3�`� �""''"T"-'``�; PRIVATE ONSITE WASTE TREATMENT county �� SYSTEMS SaWyer '�`.�5�:�:; ( POWTS) ��` '"�'�'�`' INSPECTION REPORT sanitary Permit rvo: Safety and Buildings Division (ATTACH TO PERMIT) GENERAL INFORMATION �3 _ dc{'g Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(1)(m)] Permit Holder's Name: ❑City ❑ Village C�Town of: State Plan Transaction ID#: �$ �� L C.�- �9�� - Insp BM Elev: BM Description: Parcel Tax No: (ad�, o ' N<;l �-�;1�� ', S_S,�, lR`� a� �/, ��v-9Yl—a�-�►35 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV Septic w �e �cst� Benchmark (Dv.o� Dosing Aeration Bldg. Sewer Y�.Y Holding St/Ht Inlet y Y,� � TANK SETBACK INFORMATION St/Ht Outlet `1Y 53' TANK TO P/L WELL BLDG vENrTo ROAD Dt Inlet AIR INTAKE Septic �a ` .�� NA Dt Bottom Dosing NA Installation Contour Aeration NA Heatler/Man. 4`f, ('7 Holding Dist, Pipe PUMP 1 SIPHON INFORMATION Infiltrative Q3 �.� + Surface Manufacturer Demand Final Grade Model Number GPM TDH Lift Friction Loss Sys Head TDH Ft Forcemain L Dia Dist. To Well DISPERSAL CELL INFO MATION DIMENSIONS IN 3� L Q �, #of Cells Type of System Distribution Media Manufacturer: SETBACK OHWM of Nav � Conv ❑ Aggregate � , INFORMATION P/L Bldg Well Waters � IGP � Chamber ' ❑ AG o EZFIow Model Number: CELLTO '� �-�j (�/ ❑ Mound o Other �Y fi — -- -- —— _-- ---- - DISTRIBUTION SYSTEM X Pressure Systems Only — --- _ _— __ _._ -- — Header/Manifold Distribution Pipe(s) j X Hole Si�ze �X Hole Observation Pipes Length Dia Length Dia Spac ! I Spacing ❑Yes ❑ No � ----- --- -- --- -------- �---- SOIL COVER --- ---- _ _--- ----- — --- Depth Over Depth Over epth of Seeded/Sodded Mulched Cell Center Cell Edges I Topsoil ____ I ❑Yes ❑ No � ❑Yes ❑ No 1 COMMENTS: (Include code discrepancies, persons present,etc.) ��,.�11� ��9 �23 Plan revision required?❑Yes❑ No �O 3 0� �� ` i /�j '�l/ � — �-- � C� fv Use other side for additional information Date POWTS Inspector's Signature Certification Number SBD-6710(R.3/01) A�OITIONAL COMMENTS AND SKErpTCH SANITAAY PERMIT NLIMBEA: ��'O�p �>Qy.� X�1 � -�� `\ w;� ��, y �� C � $ 5` ��L 3 �b � �- - , �� , �-- a� --� , 1��' �� l 1��3`� -�-- ��_--