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010-941-16-3405-SAN-2023-204
� ` Indu�hY 3arica DSvision Ca�ty � .,�� " . 1400 E Wathin�ton Ave W '(f i:�s� �F' ' P.O.Bmc7t62�_ �. `: , Smpu9Pmmt (robe�ned'mby � Z � {.•' M�diwn,WI53T07 7162 � 7- Co S I �o�! �, Sanitary Permit Application ��'°"°�°°''`� � ���msrs���c�.w�,.�.c�..��r�.���.��� �'W"�d P�m°��Ya�r r�►'T�Apn��.�d��ema rowrs aiemumMea m r�ennmms Qrmebmcmm mtl&�,aa � �MDapuNunt of�ety v�d Prollealoml Saviee.Panm�l�Ym+P���4'be uted ir ternodey in�whhHxPd LwalS. 1 Sutr. � Sa�. i. ietw�matloe—TleeaPrtatA9laPomm�on Pr�°`ro"uc�. r'°�t* o�o-4Y1-�6-3yos ��y�'SarJ 1- 1-09-16-3 0 -aoo-c�vo� PropenY Ow�er'o ,I p�Y 109D l.tJ' I�"hr/I Q� �,�.� «n.smc� a� rr� 5� w, sw �,sm� b u.�����W.u�mu.�3 5y r�: T�i�: x��«� �6���F.m„��,�_,��� N �3 � ❑�b�-�� �. — ❑�.� ❑s�.�-���� �� ❑�� 2/� �D �Tamof AY UL 7ype ot Pamlt(C6a�only we boi on�e A.Co�ilm B tfappUcabk) A. ❑New3Yskm �Rq��9yu� ❑LatmmNHoidingTatReAl�mt�lY ❑OtlxrMo�iwroExWni�(�P�T s. ❑r�rx�et ❑r�a�� ❑c��� Qr�u�mrr� u�a�.es�ax�maorerm�ea s��,w� o�. qS-o43 , 3��7 �9q�- N. ot POW'['3 s ke: C9MJc t11 tlat �Non-PianQiud k-0comd ❑Amu[iad Io-(�mmd ❑At-0tade �Momd>24 m.ofmiubkm7 ❑Mwnd<Z4 m.ofsmubkso0 ❑Noldiaa Tank ❑OtharDlrymal ComP��icxD�+iel ❑Aq�whoant Davia te�phinl V.D UTreatment Axa�Iot'urmutop; D�cgn Flow Ippd) psiW Soi1 p�1�mWn DiRew!p�ea Re�pGed(sfl �It�assl Atn Prapaaed(s� Syat�Elavatim 600 . ,� Zao * i2oo ia .�' 9o.a, V1.Tanlci�e capdrym oeoi �of hl�a�er (7a(bnc GRau Ilnfb �� �� � �� � I�v1'�S E�Tadt °i�COt�� I 6U 2 2 iC�e� �� V1I. 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" `"`� ; PRIVATE ONSITE WASTE TREATMENT co�nty ,, -� �`�'�°s ,��, SYSTEMS S2,Wyer '.� �� % ( POWTS) �iHti_`_/�i. �"�>""y,"' INSPECTION REPORT sanitary Permit rvo: Safety and Buildings Division (ATTACH TO PERMIT) GENERAL INFORMATION o�3 ^o2b Y Personal infonnation you provide may be used for secondary purposes[Privacy L,aw,s. 1�.04(f)(m)] Permit Holder's Name: ❑City ❑ Village Town of: State Plan Transaction ID#: S�fi�' �9��,so� �-�A,�,,,� � insp BM Elev: BM Description: Parcel Tax No: C�f7-vr N„(;1 �� �b« (�►�'���t"�. r'�"'�- D IO -4Y(��� -3Yo� l TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV Septic �.n��f �..�D � Benchmark �oo.o ' Dosing Aeration Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION St I Ht Outlet �po,7 ' TANK TO P/L WELL BLDG vENrTo ROAD AIR INTAKE � �v�•S f Septic NA B�Bet�em- �o o,�{ � Dosing NA Installation Contour Aeration NA Header/Man. �t3,p ` Holding Dist. Pipe PUMP 151PHON INFORMATION Infiltrative Surface Manufacturer Demand Final Grade Model Number GPM SYS• � �2.� � TDH Lift Friction Loss Sys Head TDH Ft $ys. � `Y( ,36' Forcemain L Dia Dist.To Well DISPERSAL CELL INFORMATION DIMENSIONS W L ���` #of Cells Type of System Distribution Media Manufacturer: SETBACK OHWM of Nav � Conv ❑ Aggregate �� , INFORMATION P/L Bldg Well Waters � IGP � Chamber ❑ AG ❑ EZFIow Model Number: CELL TO -f-(�j � � N ❑ Mound o Other �,�� -- --- -�-- -- - --_ _--- _ _ -- - __-- --- - _- DISTRIBUTION SYSTEM X Pressure Systems Only _ __---- -- _--_ --- - Header/Manifold Distribution Pipe(s) X Hole Size � X Hole Observation Pipes Length Dia Length Dia Spac � � Spacing ❑Yes ❑ No � - -- --- - - — - - --- - -- 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.) ��Il�� �� (b (� 3 � _ _-- - Plan revision required?❑Yes � No I' J I - � � - —� ''b3 �t8 r � � ��--- �- - -1 G9S� l� Use other side for additional information Date POWTS Inspector's Signature Certification Number SBD-6710(R.3/01) AODITIDNAL COMMENTS AN� SKETCH SANITARY PERMIT NUMEER� � 3� a'�� -----___--------- � S �A/ Y� I ' � � a��M� I � � _ � , �c 4� � � C�aLV� � � \ � 1 � Q��,�,�. s�-� � �� � r � ,a- a ` ;� ��� "�.};�-� „�•I� O . 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