HomeMy WebLinkAbout026-131-00-1601-SAN-2023-142 � �- "` " Department of Safety c°°°ty �
,� � = & Professional Services, S Gw �"r �
= Sanitary Permit Number(to be filled in by
'= Industry Services Division
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Sanitary Permit Application State Transaction Number 1
In accordance with SPS 383.21(2 j,Wis.Adm.Code,submission of this form to the appropriate govemmental unit �
is required prior to obtaining a sanitary permit.Note:Application forms for state-oµned POWTS are submit[ed to Project Address(if difterent than mailing ac �
the Department of Safet� and Professional Services.Versonal information you provide may be used for secondary
purposes in accordancc with the Privacy Law,s. 15.04(i)(m),Stats. �' � ��j� }�J A Z G� RC���
L Application Information-Please Print All[nformation
Property Owner's Name Paroel#
_.i a U�bo.c. � - 1 t -00 0 I
Property Owner's Mailing Address Propert}L.ocation
� 0 q 5 N o r d�G ��t N Govt.Lot
City,State Lip Code Phone Number
�Alesl-l..aV•�-��•�d �"�N 5508 l '/<. v4, sect�o� la
II.Type of Building(check all that apply) \ Lot# p/O 1 L + �'7 T N R O W
�l or 2 Family Dwelling-Number oYf3edrooms v1 a Subdivision Name
B���k� I-�;11S�c1e A L cs
O Public/Commercial-Describe Use
❑City of ___-----
❑State Owned-Describe Use CSM Number ❑Village of
'7'7'19 �r��»or S�,.d C.c Ke
[II.Type of POWTS Permit:(Check either"New"or"ReplacemenY'and other applicable on line A. Check one box on line B.Complete line C if
a licable.
A.
❑ New System ❑ Replacement System �[Other Modification to Existing System(explain) ❑ Additional Pretreahnent Unit(explain)
�-a.a� .��.., l�e�a;� -r�.x
B' ❑ Holding Tank �In�round �jCe�} ❑ At-Grade
❑ Mound ❑ [ndividual Site Design ❑Other Type(explain)
(conventional)�,��
��• ❑ Renewal Before ❑ Revision ❑ Change of Plumber ist Previous Permit Number and Date[ssued
❑ "Cransfer to New Owner �� � �� � ���3 �
Expira[ion
IV.Dispersal/Treatment Area and Tank[nformation: (�•o1S � X �o ol� C c 1 I tv/ G b {� (,�e.oa.�, �
Design f low(gpd) Design Soil Application Rate(gpd/s� Dispetsal Area Required(s� Dispersal Arca Proposed(s� System Elevation
3c� o 0.8 /a. 0 37S / ��0 3"75/�4S � 95•�7'7
Capacity in Total #of Manufacturer �
'i'ank Information Gallons Gallons Units � � o � �
New Tanks Ezisting Tanks � o i; � y � "a c`"d
Cp Md�1 An1 n. c� �n �, v� u, �7 a
Septic or Holding Tank �_ t O C'✓ � p e
J��
DosingChamber ,.�. 7SO 7 rn
J�J
V.Responsibility Statement- l,the undersigned,assume responsibility for installallon of the POW'CS shown on the attached plans.
Plumber�s Name(Print) Plumber's Signature MP/MYRS Number Business Phone Number
� 1�� s���►+z Is� c�tag ��s-ss - v4
Plumber's Address(Street.City,State,Lip Code)
'70"1 Co f�l S�-o�ne l...�1Cc 1�� s��'ne I..o.Kc W= Sya�7l�
VI.C untylDepartment Use Only
�,Ap ❑Disapproved Permit Fee Date(ssued Issuing��gent Signalure
❑Owner Given Reason for Denial $ I(�(J,� � '� <� I� 3 " 1
Conditions of ApprovaUReasons for Disapproval
� ��-3 r-� ���-
$,; °!'� �ate?---� . __ ,._ -� �,� J U L 1 0 2023
�� ' ��C i� ��
�hk#
�T. �31 O� a��t# �.a 5 o SqWYER COUNTY
I ZONING ADMINISTRATION
`-t l;`��C l;
Attach to c plete plans for the system and submit ro the County only on paper not less than 8 in x 11 inc es io size
NO RiFJND�AFT�R � ���ky S
sB�-639s�R.osizz> 1�3UE OF PER�V�iT J '
GeoMat IN GROUND AND DOSING DISTRIBUTION COMPONENT DESIGN
Residen.. �� �.
INDEX AND TITLE PAGE
All Water Trc
ne"r _ .
Project Name: Urban-Runzel Rd
Owner's Name: Jay Urban
Owner's Address: 1095 Nordic Ave N
West Lakeland,MN 55082
nfo
Property Address: 5790N Runzel Rd
Legal Description: S 22 T 39 N R 9 W
Township Sand Lake County: Sawyer
Subdivision Name:
Lot Number: 2 Block Number: CSM#: 7749
Parcel I.D.Number: 026-131-001601
Plan Transaction No.:
Page 1 Index and title Page 9 Plot plan
Page 2 Data entry Page 10 Pump Curve
Page 3 GeoMat dist.cell drawings&calculations
Page 4 Lateral and cell cross section
__ _
Page 5 Management&contingency
Page 6 Maintenance 8 specifcations _ _
Page 7 Tank cross sections
Page 8 Oistribution media
Dylan Schul� License Number: ���4�ag
Date: O6/07/23 Phone Number: (715)558-5904
Signature:
Designer Sta State of Wisconsin Approval Stamp:
Designed Pursuant to the
GeoMat In Ground Component Manuai April 2019 Version
Page 1 of 10
In Ground and Dosing Distribution Component Design
ite Infortnation
R Residential or Commercial Desfgn N ISD Required?
200.00 Estimated Wastewater Flow(gpd)
1.50 Peaking Factor(e.g. 1.5= 150%)
300.00 Design Flow(gpd)
2.00 Site Slope(%)
95.77 Prop. System Elevation(ft) Sand&Native soil Contour
55.00 Depth to Limiting Fador(in)
� 0.80 In-situ Soil Application Rate(gpd/tl�)
97.89 Lowest Original Grade Ele. In System Area (ft)
98.35 Highest Original Grade Ele. In System Area(ft)
� 93.77 Limiting Factor Elevation (ft)
1.08 Depth Below Grade
s utlon e n rm on :
325 Cell Width(ft) 1 Number of Cells
2.00� Dispersal Cell Design Loading Rate(gpd/ft�)
2 Influent Wastewater Quality(1 or 2)
s u on n rmation
E Center or End Manifold, Dist. Boz or Drop Box
7 Number of Laterals System dosed Y
0.00 Lateral Spacing(ft)
11.42 Forcemain Drainback(gal) Does the forcemain drain back9 Y
� 1.90 Forcemain Filter Loss(ft)
2.00 Forcemain Diameter(in)
70.00 Forcemain Length(ft)
91.67 Inside Pump Tank Elevation(ft)
3 50 System Head (ft)x 1.3
4.87 Vertical Lift(k)
1.39 Friction Loss(k)
�1 66 Total Dynamic Head(k) Designer must enter fr�ction bss and system demand (gpm��,
41.42 Minimum Dose Volume(gal)
25.00 System Demand (gpm)
anu aeturer rtn b�_ . .
Treatment Tank Infortnation Effluent Filter Infortnation
1200.00 Septic Tank Capacity(gal) pressure filter only Filter Manufacturer
Skaw Precast Manufacturer Na Filter Model Number
Dose Tank Information Gallonsllnch Calculator��.cpbonap
754.35 Dose Tank Capacity(gal) 754.35 Total Tank Capacity(gap
16.05 Dose Tank Volume(gal/in) 47.00 Toial Working Liquid Depth(in)
Skaw Precast ��.Manufacturer � 16.05� gal/in(enter result fn cell DoseTankVolume)
Project: Urban-Runzel Rd Page 2 of 10
In Ground Plan View
IL � c��IlIl c����I��:
- I
'. °o�o o°o°o°o o°o°o o°o°o°o�o°o�o°o°o�o°o�o°o o°o�o°o°o°o°o�o°o�o 0 0�0°0°0 0°0 0�0°0�0 0°0°0° '� �
'. °o�o°o�o�o�o�o�o�o�o�o�o�o�o°o�o�o°o�o°00000000 0 0 0 0 0 0 0 0 0 0 0 0 00°0�0 0�0°0 0°0°0 00 .' ^
. o0000000000000000000000 0000000000 .' I
. o0000000000000000000000 � �Q 0000000000
'- °o�o°o�o�o°o°o�o°o°o o°o°o�o�o°o°o°o�o�o°o°o�o ��.1`�✓H'6�. o�o°o°o�o o�o 000000 .'
00000000000000000000000 0000� 00000 .
5.... � �.. . .. . ._ . .. ... .. .. �
I ft A 325 ft Basal Area Required 375 ft`
K 1 ft B 60 ft Basal Area Proposed 375 ft2
S O.00ft L 62k
W 6.25 ft
Basal Area Calculation GeoMat Dis ersal Cell Basal Area Calculation
GPD Loadin Rate GPD Loadin Rate
300 0.8 gausq tuday 300 2.00 gausq tuday
Total 375 ft2 Total 150 ftz
Proposed 195 ftz
Number of Cells 1 GeoMat Width 3.25 ft
Cell Length ft Lineal Feet of GeoMat Required 462
Min. Cell Len th 462 ft Lineal Feet of GeoMat Proposed 60
Cell Spacin 0.00 ft NOTE:Min S dimensfon= 1'
S stem Elevation 95.77 ft
Limitin Factor 93.77 k
Se aration 2 ft z'rotin
Directions
Play with cell length to get desired cell spacing, length and width. Remember sys;em SHOULD be ionger than it is
wide It must also Satisf basal loadfn rate and GeoMat cell loadin rate
Project: Urban- Runzel Rd Page 3 of 10
End Connection Lateral Layout biagram
L%
// . , _, �_ . ,_ ,
' � . .. _ , _- - - �_J.,r . ._. , . _ ., ..
. . . . . . . . . _ . . _ . _ . ,.�. . _ . . .. _ . . .. _
. .. . ..,. _- . . . _. . . . .
l., J _ ' �l�T�, . _ _
Hole spacing is every 12" , 1/2" hole at 4 & 8 O'clock, starting 4 O'clock 6" from end and
8 O'clock Hotes at 12"from end. 4" Perforated pipe may be used.
Laterai Spacing 0.00 ft Pipe Diameter 2.00 in
@ POS$ @C Of1 . . _ , ,. ,. _ _, - _ _ .
�'iniched C_.nAc ` `r ` Y `t ` `fY `�
� :. . _.: . ._ . _ . '�. `�. Q1�OC
12 -42 `eae►fq :� 1 ' : IJ9tlalI.evd
� ' , �._�=
1.08 ft '— Smd C°�a n°°mme°d°d
G : _ ` ; — . . . . .. •.
T` ��' ia�QztvO
2 in —s PipeDii • • . � �„u ' �. � . . Ftbtic
� . � r�a �.� �
_ . .. ,�
Top of geomat to be at or �. _ _ - � GEO MAT
below originai grade � � � I � 1 � Z■A� 33 �� 1 i I , I � I � I �
- - — - - - _. ,� � - —
IaSluative Snrface
-cy - - - J-NATIVE.SOIL- ^
I _ _ _ _ _ _ � � � .� � _ _ ._ � .� � L�^-itaA Fr,t�
SSin y �
_ ., �_. � _ .. .,
.serva on' pes ' _ _
���
P�6ed�de
II
!
i ' 4•Gim Di�
12" Min.
42" Max. �
i
i 5�°°"
Toil�K Planec , ` Rcbar
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OPANAT -'� �� .f.T :� �'�
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95.77
Project: Urban - Runzet Rd Page 4 of 10
Notes/Maintenance Requirements
MANAGEMENT PLAN
This private onsite wastewater(POWTS)has been designed,and is to be installed and maintained in accordance with SPS 383,Wis.Admin.
Code,the in-Ground Soil Absorption Component Manual for Private Onsite Wastewater Treatment Systems Version 2A SPS-10705-P
(N.01/01). GeoMat in ground Component manual Apri12019 Version.
1.This POWTS has been designed to accommodate a maximum daily flow ot 30Q�9Aons of wastewater per day. The quality of
inFluent discharge into the POWTS treatment or dispersal component shall be equal to or less than all of the following.
A monthly average of 30 mg/L fats,oil and grease
A monthly average of 220 mglL BOD5
A monthly average of 150 mg/L TSS
Wastewater shall not discharge to the POWTS in quantities or qualities that exceed these IimRs or that resWt in exceedfng the enforcement
standards and preventative action limits specified in ch.NR 140Tables 7 8 2 at a point of standards application,except as provided in DSPS
383.03(4),WisAdmia Code-
2.The owner of this POWTS is responsible for system operation and mafntenance.
3.Detects or malfunctions identifed dunng maintenance descnbed above shall be repaired in conformance with SPS383 Wis.Admia Code,
and the pertaining county Private Sewage Systems Ordinance. The user's manual,provided to the owner of the POWTS includes the names
and telephone numbers of the properly licensed individuals to contact for such repairs.
5.No produd for chemical or physfcal restwation or chemical or physical procedures for POWTS may be used unless approved by the Dept.
of Commerce in accordance with SPS.384,Wis.Admin.Code.
6.If the POWTS is replaced,or its use diswntinued,it shall be abandoned in accordance with SPS 383.33,Wfs.Admin.Code.
NOTES
Two Efflueot Filters to be installed where possible 1 to be installed fn ST,and or i in pump tank in
order to insure partfcle size less than or equal to 7/8". Filters should 6e cleaned once in spring,and once in fall.Also,strainers in sinks in
the building shall be maintained,so that solids and fats are minimized to flow into system.
A minimum of 2 observation pipes per cell shall be installed.These pipes shall be located approximately at the end of each cell.
The plumber,or county shall see to it that a copy of these plans including thfs page,maintenance folder,and maintenance agreement is
given to the homeowner.
This system may contain a dose chamber_ If a pump,floal,elecMcai outage causes the dose tank to fill,the homeowner should see to it that
the effluent level in the tank is brought down gradually and not all dosed to the system at once. One large dose could cause damage.
Contact a pumper or your installer if this problem occurs.
The homeowner is responsible for formulating a water conservation plan that will ensure the system is rareiy overloaded. LE.spread laundry
out over time,not 6 loads in 2 hours,while everybody showers,and uses the toilet,ETC.
CONTINGENCY PLAN FOR COMPONENT FAILURE
A.Septic Tank.Any structural failure resulting in cracks or leaks in the tank must be corrected by replacement of the septic tank component.
Leaks in the joints between manhole risers or covers shall be repaired by replacing faWty seals with approved materials to make joints water-
tight.
B.Outlet Filter.The outlet filter shall be replaced or repaired wheo it is either no longer capable of preventing the discharge of partides larger
than i/8 inch or when it has become permanently degratled by clogging so as to fnterfere with the design flow out of the septic tank.
C.Dosing chamber and pump.The dosing chamber shall be replaced if any stmctural failure is found Leaks in joints between manhole
risers or covers shall be repaired by replacing faulty seals with approved materials to make joints water-tighL The pump and controls shall be
replaced when they are no longer capable of functioning according to the design plan.
D.Pressure Distributfon Piping.Partial clogging of the distributfon nelwork may result in unduly long dosing cycles.The ends of the
distribution laterals may be exposed and the threaded end caps removed.The piping can be disconnected on the outlet end of the pump.
The distribution piping may then be back flushed to cleanse any accumulated matter from the piping.It is rewmmended that the dosing
chamber then be pumped by a licensed plumber.
E.Soil Absorptlon CeIL The discharge of sewage or wastewater to the ground surface is stnctly prohibited tlue to the human health hazard
created by the effluent.Ail failures created by surface discharqe shall fmmediately be repoded to the appmpriate county.The pump shall
then be immediately dfsconnected to prevent further discharge to the ground surface via the soil absorption cell.The ezisting septic tank and
dosing chamber shall be used as a temporary holding tank until the necessary repairs to the soil a6sorption cell can be achieved.The
replacement shall be initfated onty after any necessary plan approvals have been obtained from the
appropriate plan review authoriry and the required sanitary pertnit is obtained from the county.
Project: Urban-Runzel Rd Page 5 of 10
In Ground System Maintenaace and Operation Specffications
Service Provfders Name Dylan Shulfz Phone (715) 558-5904
POWTS Regulator's Name Sawyer County SPIA-Zoning Adminisiration Phone (715)634-8288
Svstem Flow and Load Parameters
Design Flow- Peak 300 gpd Maximum Influent Particle Size 1/8 in
Estimated Flow-Average 200 gpd Maximum BODS 30 mg/L
Septic Tank Capacity 1200 gal Maximum TSS 30 mg/L
Soil Absorption Component Size 195 ftZ Maximum FOG 10 mg/L
Type of Wastewater pomestic Maximum Fecal Coliform 10E4 cfu/100 mL
Service Frequencv
Septic and Pump Tank Inspect and/or service once eve 3 ears
Effluent Filter Ins ed and clean as necessa at least once eve 3 ears
Pump and Controls Test once eve 3 ears
Alarm Should test eriodicall
Pressure System Laterals should be flushed and ressure tested eve 3 ears
In Ground Insped for ponding and seepage once every 3 years
Miscellaneous Construction and Materials Standards
t. Observation pipes are slotted and materials conform to Table SPS 384.30-t, have a watertight cap
and are secured in as shown in the GeoMat In Ground Component Manual Ver. April 2019.
2. Dispersal cell media conforms to GeoMat products approved for use with the GeoMat In Ground Component
Manual Ver April 2079. Media is covered with an approved geotextile fabric.
3. All gravity and pressure piping materials conform to the requirements in SPS 384,Wis.Adm. Code.
4. Scarification of basal area is accomplished with a rake or other tool.
5. All disturbed areas will be seeded and mulched to prevent soii erosion and help reduce frost penetration.
Lateral Turn-up Detail
6-8"Diameter F�nished Threaded Cleanout
Lawn Sprinkler Grade \ Plug O�Ball Valve
Box \
y Vent if i � ot Dosed
� Lateral Ends at Last Orifice where
� Long Sweep 90 or Two
�45 Degree Bends Same
Diameter as Lateral
� �Disvibution Lateral � � Lateral Cleanout
95.77 Feet
Projed: Urban-Runzel Rd Page 6 of 10
PAGE � OF �
GRAVITY-DOSED 7 �� �_
—
SEPTIC / PUMP TANK SPECIFIGATIONS
4•fdVentPipe (No Scale)
>10 ft from
Building Electrical must comply with
12"Min. or 2.0 ft above COMM 16 and NEC 300
Established Flood Elevation Weatherproof Extend manhole riser as necessary.
(typical) Junction Box
Approved Approved Locking Manhole
(MPORTANT: VentCap with Waming Label Attached
Anchor tank(s) as necessary � �tyP��'�
pursuant to SPS 383.43(8)(g) ~"��nduit
4" Min. or 2.d ft above
Established Flood Elevation
� (tyPical}
�Airtight Seal '
Finished Grade
" Quick Disconnect
e
18" Min.
CAPACITIES @ 16.05 gal�n �: - � .. e . . � - � • c�vP'�'>
a �
Depth (in) Volume {gal)
A 32.42 520.34 * �—APProvedJointswith
�P Approved Pipe 3 ft orrto
Liquid HOIe Solid Ground
B 2.� 32.10 A Depth Force Main �tYP"���
� Fiiter*
[C] 2.58 41 .42 �—
Aiarm *�nstail and maintain pursuant
� � �.�� 160.50 �B ; o� to manufacturer's instruc6ons.
I � � PUMP-OFF
* 47 � P�mp orf : ELEVATION = 92•50 ft
Pump Tank �iquid Level = in
° INSIDE BOTTOM
Force Main Diameter = 2 in Concrete
B��k ELEVATION = 91 �67 ft
. : . . . . . � e ..
3"Approved Bedding Material Beneath Tank
Force Main Length = �� ft
Force Main Vaid Volume = 11 .42 gal
[C] Total Dose Volume TDV = 41 .42 gal/dose
( < 0.2X design flow + force main void volume)
Vertical Lift = 4'87 ft
PUMP TANK: SEPTIC TANK�S):
Volume = 754.35 gal Total Volume = 1200 ga�
Manufacturer: S�W Precast Co Manufacturer(s): S�W Precast Co
Pump Manufacturer: Liberty
Install approved force main filter pursuant to
Pum Model: 25� manufacturer's instructions.
p (See attached pump curve.}
Controls/Alarm Manufacturer: SJE Rhombus Filter Manufacturer: Simtech
Controls/Alarm Model: PS Patrol
Filter Model: STF-100
Float switches containinq mercury are prohibited.
6eoMat DbMbutlon Cell Media Layout
3.25 Cell Witlth(k) 2.63 Sitlewall to Lateral(ft)
Distribution Cell Cross-section Arrangements
`�
Po� 4e
O Distribution Pipe
GeoMat is coveretl with approved geote�ctile fabnc as per Ihe their protluct approval.
Distribution Cell Plan View Layout-Typical
3.25 Cell Width-A(H) 60.00 Cell Length-B(ft)
LnCCOI,�iE't;'J0l'i_d;_�.i;��� ..� . ...
�F __-_-___ . ._ .. .. .. . . .____._ . _ .. . . _- ��1.
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.__ .. . , . . ca �peraa e . . .. ... ... ..... .
F:�:�hcd C:rnAc �`�` Y `� ` W�7
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12 42��' B'e�f9 : �39�V I.CYf�
$m4 COR IeOa�[OdOQ�
4 __T..
p�� _ �^ „v �� Flafittnrir°
P�K I�-
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I � I I I I I 2•ASTM�33 c�- I � I ' I ' I � I �
� . —— — — J J——————_ IaSkntivs Surfaee
ay I -_NATIVE.SOIL=_-J__�
1 f_= ---��----'==- L'a�i�nv,Far�a
1
see aetaas o�Paye<ror n�moer,s�e,ara spac�ng rn�erais.
Project UrDan-Runzel Rd Page 8 of 10
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250 P I R l/17(2018 <c�Copyright 20I8 Liberty Pumps Inc. All rights reserved. Specifications subject to change without nonce.
Pum"ps�
, � "'"'" � ; PRIVATE ONSITE WASTE TREATMENT co�nty
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���'� �, SYSTEMS SaWyer
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' '�"'� INSPECTION REPORT Sanitary Permit No:
Safety and Buildi�gs Division (ATTACH TO PERMIT)
GENERAL INFORMATION �3 �- I �(�
Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 1�.04(1)(m)]
Permit Holder's Name: ❑City ❑ Village � Town of: State Plan Transaction ID#:
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Insp BM Elev: BM Description: Parcel Tax No:
�o�t'� � a� T��1�C, n yzf- (f-� 0�-6 - l3(-60-�:�O�
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic ���j - l�-ao Benchmark �pp,��
DoSing r-c v�-�.� ��
Aeration Bldg. Sewer
Holding St/Ht Inlet
TANK SETBACK INFORMATION St/Ht outlet
TANK TO P/L WELL BLDG VENT TO ROAD Dt Inlet
AIR INTAKE
Septic '�"S }�,S .� o� ��p� NA Dt Bottom `��S�S�
Dosing �� �, � y NA Installation 9�'3 i
Contour
Aeration NA Header/Man.
Holding Dist. Pipe �''7.2�'
PUMP 151PHON INFORMATION Infiltrative
Surface `��?��
Manufacturer (,� Demand Final Grade
Model Number 2 S' GPM � C33 ��?7�
TDH� Lift Friction Loss Sys Head TDH Ft
Forcemain L �-( ' Dia �'' Dist. To Well
DISPERSAL CELL INFORMATION
DIMENSIONS W (,2j � 'j #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate �o���-
INFORMATION P�L Bldg Well Waters °� GP ❑ Chamber Model Number:
❑ EZFIow
CELL TO ��'v t .1-Sp` N ❑ Mound �C Other
-- -- - - - ---- — — -- - --_—_._— _—----
DISTRIBUTION SYSTEM X Pressure Systems Oniy"
Header/Manifold �Distribution Pipe(s) X Hole Size X Hole Observation Pipe�
Length Dia Length Dia Spac I� Spacing ❑Yes ❑ No
-- —_ __---
SOIL COVER _
De th Over De th Over � De th of Seeded/Sodded Mulched
Cell Center � Cel�l Edges ; Topsoil _ _ ___� ❑Yes ❑ No ❑Yes ❑ N�
COMMENTS: (Include code discrepancies, persons present,etc.)
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Plan revision required?�Yes❑ No I��3 ; �� �Y, - � ; /�� �� �
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Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AOOITIONAL COMMENTS ANO SKETCH
SANITARY PEflMIT NUMBEA: �_-.�_�{�_
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