HomeMy WebLinkAbout010-941-21-3446-SAN-2023-121 o<< - �
�� / industry Serv�ces Divis�on I Coun �
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�. _ �= ✓ A1-� � Madison,Wi Si705 Sani�ary Permi.. mber(w be flled in� �
'.,y� ��. �_ ;- ��f� ,' P.O.Box'302 � 9J
����� r��7'�� Madison,Wi 53707 ��� W
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Sanitary Pelmlt AppliCatl�n StateTm�sactiooNumber .�
tn accordance u�ith SPS 3R3.21�2),Wis.Adm.Code,submi;sion of chis fonn m ihe appropnate vo��emmental unit '— I�'
is rcquircd pnor ro obtaining a sanitary permi[.Note:.4pplica�iun forms for sta�c-owncd POWTS are submicrod ro Project Address(if differrnt than mailir `�
the Departmenc of5a(ery and Professiona�Servires.Pcrsonai infortna[ion you provide may be used for secondary ' _�t-
purposes in accordance with Ihe Pnvacy Law,s.15.04(1)(m),Sta[s. � ' /'
i.Applicallon Informatlon-Please Print All informallon V �C/J O✓� �L� iv�,-�-�'•
Propercy Owncr's Namc Parccl#
A 3 �-�n.� L�C� o�ti _ �41_Z� _34u�
Property Owner's Mailing Address Property Location
�bS6� r� 0`3r«,� t�-;�� (�1, �
Gov�.Lnt
Ciry,Sta�e I Zip Code Phone Vumber
L�. I.��,�C W � 5�8�-{7j ' ��'.,.54.� '/.,Sec[ion Z�
II.Type of Building(check all that apply) � Lo^ T N R b�l H o w
�I or 2 Family Lhvellino-Vumber ofBedrooms L Subdivision Vame
Biock#
�ublic/Commercial-Dexnbe Use
��Ciry of
❑S[a[eOwned-Describelise CSMNumber illageof _
3,(��S�ass3 �Townof t-f�i.H�•�.�
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III.Type otPOWTS Permit:(Check either•`rew"or"ReplacemenP'and other applicable on line A.Check one box on line B.Complete line C i
a Ii�c'pa�bie�.
A� ��/V.'vew Sysrem �eplacement Sys[em ,�ther M1lodification ro Exis[in�System(explainj ❑Additional Pretreatmen[Unit(explain)
7-'
�m I
B' �I-lolding Tank �ryIn-Gmund �AAi-0rade �Mound Individual Sire Design OtherType(ezplain)
~��(Conventional)
C. ❑RrnewalBefore �Rrvision ChaneeofPlumber �I'ransfertoVewOwner�Cis�PreviousPermitNumberandDamLcsued
Espiration -�
IV.DispersaVTreatment Area and Tank InformaHon: -
Desi;InIF(l�ow�(gpd) Desi�n S`'o'i�l Applicaiion RatelgpNs� Dispersal Are2a Required(s� �Disp rsal Ama Pmposed(sQ Sysrem Efevation
"[7V . 1 � �i�7 6 QZ- 4�'�..-I.S�
Capaciry in Total 7+of Manufacmrcr
Tankinformanon Gallons Gallons Unics � �7� _
�euTanks Exi�tingTankx � - `_ � - n A
a C; vi h ' .s.J a
Scpo or Holding Tank I DOb �— 1�Q � W�SQr
DosinS Cham6cr i � �
V.Responsibility Statement-I,the undersi�eQ assume responsi6ili¢�for insmllarion ot the POWTS shown on the attached pians.
Plumber's hame(Pnnt) �P ,gnat re � �'vfPM1PR5�llmber Business Phone Number
�ob La�.rr� i jZz(oZ�$ Z�S-b��-o43�
Plumber's Address(Street,Ciry.Stace.Zip Code)
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VI.C unty/Department Use Only
y�Ap ❑DisapprovrA 7ermit Fee Date issued i Issuin�Agen[Signature
❑Owncr Givcn Rcazon for Dcnial
�yoo.�° � �s i .
Conditions of ApprovaUReazons for Disapprovai
Q�lG���l - �- �-a3 �� ���� �
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C�ST � _p6� � . :,r�_ao �� JUN 30 2023
COUNTY
AttncA to compleh plans(ar Ihe syscem and submit ro tM1e Counn'only on paper not less Man 8 I:E s rLC�pryq.�p;+qDMINI
NO REFUhDS AFTER
ssD-6a9s�x.ozizz) �SSUE OF PERM17
.�<r i�'� °7�`i 7�
'�"'""�",�;�: PRIVATE ONSITE WASTE TREATMENT co�nty
�'�r ; .
SYSTEMS Sawyer
`��,,�SPS �'/ ( POWTS)
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""� '- INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION a-3 � « I
Personal infonnaCion you provide may be used for secondary purposes[Privacy Law,s. 15.04(l)(m)J
Permit Holder's Name: ❑City ❑ Village � Town of: State Plan Transaction ID#:
� LLL
Insp BM Elev: BM Description: Parcel Tax No:
����� �a�l d- �1�Obc� � �-• 6�S .s' � dT�3�f"'P �l� -���'o�� '3YYlO
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic w� �p� Benchmark Io0 p'
Dosing
Aeration Bidg. Sewer �,d�
Holding St/Ht Inlet �(, o�
TANK SETBACK INFORMATION St/Ht outiet er,T 6 '
TANK TO P/L WELL BLDG vENr ro ROAD Dt Inlet
AIR INTAKE
Septic fi � (�/ 7 -F'7 ` NA Dt Bottom
Dosing NA Instaliation
Contour
Aeration NA Header/Man. 9�,� '
Holding Dist. Pipe
PUMP 1 SIPHON INFORMATION Infiltrative �3�9 �
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 �N L (� 6 � #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate L
INFORMATION P/L Bldg Well Waters � GP � Chamber Model Number:
❑ EZFIow
CELL TO � ❑ Mound � Other
---- -- -���__ - N ti - -4�----_ ___.
DISTRIBUTION SYSTEM X Pressure Systems Only
L ngthr l Manifold Dia L�en9bution Pipe(s) Dia Spa�X Hole Size � Spa�ing ❑Yes at'❑ Nloe�
SOIL COVER
— —
Depth Over �Depth Over I Depth of Seeded I Sodded Mulched�
Cell Center Cell Edges ; Topsoil _ __ ❑Yes ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present,etc.)
��,s�l�( ����/�3
Plan revision required?❑Yes❑ No II o��G1 g �Y�I '� � w __ I�I �� � (�� �
Use other side for atlditional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AD�ITIONAL C�MMENTS AND SKETCH
SANITAAY PERMIT NUMBEA: �-� Ia-�___
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