HomeMy WebLinkAbout010-941-21-3447-SAN-2023-122 b r,� . .
/j q Indus[ry Services Dn�sion Counry � .
;� � - ''�.'7 I 4S3?Madisun Yards Way 5�W -
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Madison,�l'T 53705
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.,���' p /�� P.O.Box 7302 �
\m..j �G/ f 1ladison.WI53707 �S�0,3 �
Sanit•dry PeTlnit AppilCatl�n Sta[eTnnsac[ioovur�ber W
In accordance witF SPS 3R3.21(2),Wis.Adm.Code,submis ion of this foi.n m chc appropnate povemmental unit � �
is rcquircd pnor ro obtaining a sanitary permic.Votc:.4pplica�ion fortns for s[a�c-owncd POWTS are submittcd ro Project Addrcss(if diBerent than mailin u
che Departmen[ofSafery arid Profession�J Sen�ices.Personal infurmacion you provide may be used for secondary
purposes in accordance with[he Pnvary Law,s.15.04(1)(m),S[a[s. ? a 1"
I.ApplicaHon Information-Please Print All InformaHon I bS��`� b� ���(�
Property Owncr's tiamc Parccl#
A-6 �.aw LLC v�o _ 44�_Lr- 3451'f
Property Oumer's Mailing Address Pmperty Location
IOSL7I N ���CIC� �� l�I I�,� Gov�.Lnt
City,Stace ,Zip Cod: I Phone Vumber
�ct W�r�. W� Sy�, 6oL—�loZ_63�1 -�'�.SW �.,secr.a� Z—)
II.Type of Building(check aIl that apply) Loi� T �-{ N R d ri E o
�IorZFamilyDwelling-NumberofBedrooms �__ .3 Subdivisio Vame
Block*
ubliNCommerciai-Describe Use �
❑Ciry of
❑StareOwred-DescribeUse CSMVumber illageof
3��tiS �8SS3 ,[d���^�f_ �,�Q-^�_
III.Type ofPOWTS Permit:(Check either"'.Vew"or`BeptacemenP'and other applicable on line A.Check one box on line B.Complete]ine C i
a licable.
A' �iew Sys[em ��eplacement$ysfem ,�ther Ylodification[o Exis[in,�,System(explain) ❑Additional Pretreatment Unit(explain)
B� �I-ioidingTank �Qfn-Ground �[-Grade �Mound IndividualSiteDesi O[herT
`f'(conventional) 6^ ype(explain)
�'� ❑Renewal Before �Revision .hange of Plumber �I'cansfer�o Vew OwnerList Previous Permit Number and Date lssued
Expiration i '
IV.Dispersal/Treatment Area and Tank Informatlon: G7 Z^ $,25
Design Flow(gpd) Desi�n Soil Applicaeion Ra[e(�pd/sf) Dispersal Area Re uired fsf) i Uispersai.4rez Proposed(s� System Elevation
�SD .� b'�3 f�4Z 4'i.�15'
Capaciry in Total 4 of Manufacmmr v � �
Tank inform�tion Gallons Gallons Unia � -
Vcu'Tankx ExixtingTanks V� - �
i V �v ' - C.
zp orHoldinETank �DO-� IO� �
�\$�(,
Dosing ChamSv O �
V.Responsibility S[atement-I,the undersigned,assume responcibitlty for insmllallon of[he POWTS shown on the attached plans.
Plumber's Yame(Pnnt) Plumb ' turc I MP/MPRS Number Business Phone Number
Rob l.��arre jZz(�Z�$ �iS_644_D�c31�
Plumber's Address(Strce4 City.Sraie.Zip Code)
l�54�w 5 t. Q,.� —1�1 ���I c.c�( S�ks 4 3
VI.Cou ty/Department i;se Only
❑Disapproved ' PermitF:e �.Date issued I issuing Age�e Si�ature
�l�r„� S yoo.^° ';7 s�� �..�
❑Ow�ner Givcn Rcazon for Dcniai
Conditions of ApprovaVReuons for Disapproval
7- (�-a-3
�r �������.�a�. �Ga��3 �� ����1
a o�k J U N 3 0 2023
J
C�� ��— �7�� SAWYER COUNTY
Aaach fo rompleh plans for tM1e ryshm and submit m the Counn'onl7 on paper not less Man 8 Irz x I I inches in size
SBD-6398(R.02/22) N�R�FUhDS AFTER
ISSUE OF PERiU1T
�v'l2G L ���/��
'�"'="—T"�'���� PRIVATE ONSITE WASTE TREATMENT county
='��a = SYSTEMS
,+,�SpS ,,-
( POWTS) Sawyer
h� ~-%P/
" "'-'��`" INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �3 _ ���
Personal infonnation you provide may be used for secondary puiposes[Privacy Law,s. 15.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village Town of: State Plan Transaction ID#:
���` L.LL. J�
Insp BM Elev: BM Description: Parcel Tax No:
'U17.c7� �Iq, 3-cl�t��y �� y �s,�d� ��� S��crL �l� —�l`�( �02� -- 3��{ �
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic � �� ��� Benchmark �,0 i
Dosing
Aeration Bldg. Sewer �}'7� ( `
Holding St/Ht Inlet �(�.G �
TANK SETBACK INFORMATION St/Ht Outlet q6,2 '
TANK TO PIL WELL BLDG vENrTo ROAD Dt Inlet
AIR INTAKE
Septic � ' n j �.$ .�$ NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header I Man. `�$';3 �
Holding Dist. Pipe
PUMP 151PHON INFORMATION Infiltrative ��Y 3 �
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 ATION
DIMENSIONS �N 3 L g #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate ��'�
INFORMATION P/L Bidg Well Waters � IGP � Chamber
❑ AG ❑ EZFIow Model Number:
CELL TO -}-�p �� � ❑ Mound o Other �Y�
-- — --— -- -- -- —
DISTRIBUTION SYSTEM X Pressure Systems Only
Header/Manifold I Distribution Pipe(s) �Hole Size X Hole Observation P pes
Length Dia 1 Length Dia Spac Spacing ❑Yes ❑ No
— --
SOIL COVER
Depth Over Depth Over Depth of Seeded!Sodded Mulched
Cell Center �Cell Edges Topsoil _ ❑Yes ❑ No ❑Yes ❑ No
COMMENTS; (Inclutle code discrepancies, persons present,etc.)
��5�ll�l g�2��3
-- -- ,
Plan revision required?❑Yes❑ No �3 ng ��c�� � � � � �ej�� �� �
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AOOITIONAL COMMENTS ANO SKETCH
SANITARY PERMIT NUMBER: _��_:___(�--�
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