HomeMy WebLinkAbout014-942-36-2302-SAN-2023-211 ' "`"' � Department of Safety c°°°ry�' ����„` �
,�;�
� 1� ' ` & Professional Services,
' :,, $ l;� Sanitary Permit Number(to be filled in by
r� ;J Industry Services Division �
��.'�iy � ,�a/ �S � � I � W
"�.i v�n»�t::
Sanitary Permit Application State"Cransaction Number �
In accordance with SPS 383.21(2),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-owned POWTS are submitted to Project Address(if different than mailing�
the Department of Safety and Professional Services.Personaf information you provide may be used for secondary �_
purposes in accordance with the Privacy Law,s.15.04(I)(m),Stats. / �� �t./� ' /���� ��Y �
I.Appticallon information-Ptease Priot All Tnfoemation � �
Property Owner's Name Parcel#
� � � 6'�,rv1��1� � �l� � ;� 3� � 3� �
Property wner's Mailing Address Property cation
� 75- S ./��r�3��2� L,� �_
City,State Zip Code Phone Number �, � � /
.�/l�V �lL L 1!J � � 3/ � (,s- •J `^�'/<, �� !i<. Secaon � �
I�.Type of$uilding(check ail that apply) Loc# _ T �� N R E or
� 1 or 2 Family Dwelling-Number ofBedrooms Subdivision Name
Block#
❑Public/Commercial-Describe Use ^
❑Cityof
❑State Owned-Describe Use CSM Number ❑Village of
— �Town of L_�'��i7 o i __
III.Type of POWTS Permit:(Check either"New"or"Replacement"and other applicable on line A. Check one box on tine B.Complete line C if
a licable.
`a' q New S stem Re lacement S stem
y � p y ❑ Other Modification to Existing System(explain) ❑ Additional Pretreatment Unit(explain)
B' ❑ Holding Tank �1n-Ground ❑ At-Grade � � YP � P )
U Mound ❑ Individual 5ite Desi Other T e ex lain
(conventional) �O/�'f/�r
C• ❑ Renewaa Before ❑ Revision ❑ Change of Ptumber ❑ Transfer to New Owner �st Pre�ious Permit Number and Date Issued
Expiration 1 I "' ��� �Ib l9`ll
IY,Dis�ersalfFreatment Area and'Fank Informstion:
Design Ftow(gpd) Design Soil Appiication ftate(gpols� Dispersal Area Required(s� Dispersal Area Proposed(s� System F-,le�ation �
yS� l. � `is� ��S""�� �`6� �/
Capacity in Total #of Manufacturer
::
Tank Information Gallons Gallons Units y� � J '$ N u
New Tanks Existing Tanks � o pr � v � � �
ri v �n � rn i.L C7 a
Septic or Holding Tank � � � ��� ,_�
Dosing Chamber / J � � n J
(�
V.Responsibitity Stat�me�t-I,the undersigned,asse e resp si ity foc it�stall$tion elthe POWTS n on the attached plans.
Pt��r's Name(P� t) � �Plumber Si e ��M PRS Number Business Phone Number
,� ��n.�:r+ ��� �'�s �iS- yl� �6U�
Plumber's Address(Street,Ciry,State,Zi Code)
�'��� r _i r ��' � S,P.��,..✓�2 l'..d-� ����i
VI.County/Department Use Only
�Ap�i ❑Disapproved Pemiit Fee Date Issued ls,uing Agent Signature
� O Owner Given Reason for Denial � �-`'''� c� I �" 1 a-� ������'�' �""""'r
Conditions of Appioval/Reasons for Disapproval
�i � � � � _ ;�'-� `,=%'�/� L/ �
F � .�a�� � l� �,a3 ; �
� ���' Yl��w
�
�::hk#_�� ° � ��- � AUG 2 9 2023
� S` �� — '� 1 �`��C� SAWYER COUNTY
Attach to complete plans for the system and submit to the Caunty onty on paper not less than 8 tn x 11 inches in size
I fr�fi3 �I
SBD-6398(R.03/22) NO R�FJh�S qFTER
ISSUE OF F'ER�1t,1f
eo at i DOSIN DI RI U I N
Reaidential Applir,alion
INDEX AND TITLE PAGE
ne� n o
Project Name: Hermann Geomat
Owner's Name: Dave Hermann
Owners Address: 5575 S Mayberry Ln New Berlin WI 53146
roperty n o
Property Address: 15064W Twin Bay Lane
Legal Description: SW NW S 36 T 42 N R 9 W
Township Lenroot County:Sawyer
Subdivision Name:
Lot Number: Block Number. CSM#: _
Parcel I.D.Number: Tax ID 18834
Plan Transaction No.:
n ex ages
Page 1 Index and title Page 9 Plot plan
Page 2 Data entry Filter specifications
Page 3 GeoMat dist.cell drawings&calculations
Page 4 Laterai and celi cross section
Page 5 Management&contingency ��
Page 6 Maintenance 8 specfications _
Page 7 Tank cross sections
Page 8 Distribution media
ViF� �V� L �+ License Number. ��3�`�g
�ate: �l I— o�-3 Phone Number: 7��Y�� �6c/�
Signature:
Designer Stamp: State of Wisconsin Approvai Stamp:
Designed Pursuent to the
GeoMat In Ground Component Manual Ver.June 26,2018 Version
Page 1 of 10
In Ground and Dosing Distribution Component Design
C3esiyn `JYorkshe�t
Site Information _ _
R Residential or Commercial Design N ISD Required?
300.00 Estimated Wastewater Flow (gpd)
1.50 Peaking Factor (e.g. 1 .5 = 150%)
450.00 Design Flow (gpd)
0.00 Site Slope (%)
96.40 Prop. System Elevation (ft)
44.00 Depth to Limiting Factor (in)
1.00 in-situ Soil Application Rate (gpd/ftz)
97.50 Lowest Original Grade Ele. In System Area (ft)
98.00 Highest Original Grade Ele. In System Area (ft)
94.40 Limiting Factor Elevation (ft)
0.10 Depth Below Grade
Distribution Ceil Information
325 Cell Width (ft) 2 Number of Ceils
2.00 Dispersal Cell Design Loading Rate (gpd/ft2)
2 Infiuent Wastewater Quality (1 or 2)
_
is ribution Information
E Center or End Manifold, Dist. Box or Drop Box
1 Number of Laterals System dosed Y �
7.61 Lateral Spacing (ft}
4.59 Forcemain Drainback (gal) Does the forcemain drain back? Y �
0.00 Forcemain Filter Loss (ft)
1.50 Forcemain Diameter (in)
50.00 Forcemain Length (ft)
85.00 Inside Pump Tank Elevation (ft)
3.50 System Head (ft) x 1 .3
13.50 Vertical Lift (ft)
1.39 Friction Loss (ft)
18.39 Total Dynamic Head (ft) Designer must enter friction loss and system demand (gpm)
49.59 Minimum Dose Volume (gal)
15.00 System Demand (gpm)
Manufacturer Information
Treatment Tank Information Effluent Filter Information
1000.00 Septic Tank Capacity (gal) Polylok Inc./Zabel Filter Manufacturer
Wieser Concrete Products, Inc. Manufacturer 3014-525-1/16-10,000 GPD Filter Model Number
Dose Tank Information Gallons/lnch Calculator (optional)
600.00 Dose Tank Capacity (gal) Total Tank Capacity (gal)
11 .82 Dose Tank Volume (gal/in) Total Working Liquid Depth (in)
Wieser Concrete Products, Inc. Manufacturer �� gal/in (enter result in cell DoseTankVolume)
Project: Hermann Geomat Page 2 of 10
In Ground Plan View
2 eg1�eoRifat
R
•�00000000000000000000000000000 �,g 000000000.•
'�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 ��l`Vll� o�o°o°o°o°o°o°o°o.•
000000a0000000000000000000000 00000000
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . ... . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . .. . . . . . .
. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . .
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alculations
I ft A 3.25 k Basal Area Required 450 ft`
K 1 ft B 35 ft Basal Area Pro osed 450 ftZ
S 4.36 ft L 37 R
W 12.86 ft
Basal Area Calculation GeoMat Dispersal Cell Basal Area Calculation
GPD Loadin Rate GPD Loadin Rate
450 1 gal/sq tuday 450 2.00 gausq tUday
Total 450 ftz Total 225 ft2
Propased 227.5 ftZ
Number of Cells 2 GeoMat Width 325 ft
Cell Length ft Lineal Feet of GeoMat Required 692
Min.Cell Len th 34.6 ft Lineal Feet of GeoMat Pro osed 70
Cell Spacing 4.36 ft NO7E.Min S dimension=1'
S stem Elevation 96A ft
Limitin Factor 94.4 ft
Se aration 2 ft 2•Min
Directions:
Play with cell length to get desired cell spacing,length and width Remember system SHOULD be longer than it is
wide. It must also Satisfy basal loading rate and GeoMat cell loading rate.
Project: Hermann Geomat Page 3 of 10
End Connection Lateral Layout Diagram
6:aE§'.
��
Hole spacing is every 12" , 1/2" hole at 4 & 8 O'clock, starting 4 O'clock 6"from end and
8 O'clock Holes at 12"from end.
Lateral Spacing 7.61 ft Pipe Diameter 4.00 in
istribution Ce I Cross ection
� ��Y � ��YV/
ss n F;�;�,�.e c:���
� 1 I-�' . _.' '-`�. :' �. .. '-. 12"-48" .eae►fitl. �..,.�: �
I •
� a 1 n — sm3 co.s ieeommmded .:
� ` �,
4 in —► �� , • . • � �%u �� ��� - = . , . '. . , FjGfilIIfIIvC
� . . . .A Pipt �\:..'_' ' ' .
Top of geomat to be at . �. .- � � GEO MAT
or below original grade � � � 2�p�.M 33 �x� I � I , I � i � I �
I I I , I � ���S�
- _ ^ �. ;r : �
— _- � _ _ _ _ _ � .�
r - - - _ � .� �
�NATIVE SOIG. � � �
rr „ - � _ - � � � � � � � - ._ _ � �� � L�F.�
�
ervatwn Pipes
���
sa t �^�
.•�A.
12" Min. '
�
48" Max. '
i
' Sloo
Toilet Flan e � Rcbar
�flSY.
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mtr4�a�
09C$QA' - . o`��.
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96.4 f
Project: Hermann Geomat 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 2.0 SPS-10705-P
(N.01/01). GeoMat in ground Component manual Version 1.
1.This POWTS has been designed to accommodate a maximum daily Flow of 45Q,�1 ons 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 mglL TSS
Wastewater shall not discharge to the POWTS in quantities or qualities that exceed these limits or that result in exceeding the enforcement
standards and preventative action limits specified in ch.NR 140Tables 1&2 at a point of standards application,except as provided in DSPS
383.03(4),Wis Admin.Code.
2.The owner of this POWfS is responsible for system operetion and maintenance.
3.Defects or malfundions identifietl during maintenance described above shall be repaired in conformance with SPS383 Wis.Admin.Code,
and the pedaining county Private Sewage Systems Ordinance.The user's manual,provided to the owner of the POWTS includes the names
and telephone numbers of the properiy licensed individuals to contact for such repairs.
5.No product for chemical or physical restoration 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 discontinued,it shall be abandoned in accordance with SPS 383.33,Wis.Admin.Code.
NOTES
Two Effluent Filters to be installed where possible 1 to be installed in ST,and or 1 in pump tank in
orderto insure particle size less than or equal to 7/8". Filters should be cieaned 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 celi 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 this page,maintenance folder,and maintenance agreement is
given to the homeowner.
This system may contain a dose chamber. If a pump,float,electriwl outage causes the dose tank to fill,the homeowner shoultl see to it that
the effiuent level in the tank is brought down qradual�y and not all dosed to the system at once. One large dose could cause tlamage.
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 rarely overloaded. I.E.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 resWting in cracks or leaks in the tank must be wrrected by replacement of the septic tank component.
Leaks in the joints between manhole risers or covers shall be repaired by replacing faulty seals with approved materials to makejoints water-
tight.
B.Outlet Filter.The outlet filter shall be replaced or repaired when it is either no longer capable of preventing the discharge of particles larger
than 118 inch or when it has become permanently degraded by clogging so as to interfere with the tlesign Flow out of Ihe septic tank.
Q Dosing chamber and pump.The dosing chamber shall be replaced if any structurai faiWre is found.Leaks in joints behveen manhole risers
or covers shall be repaired by replacing faulty seals with approved materials to make joints watertight The pump and controls shall be
replaced when they are no longer capable of functioning according to the design plan.
D.Pressure Distribution Piping.Partial clogging of the distribution network may resWt in unduly Iong dosing cycles.The ends of the
distribution laterals may be exposetl and the threaded entl caps removed.The piping can be disconnected on the outlet end of the pump.
The distri6ution piping may then be back flushed to cleanse any accumulated matter from the piping.It is recommendetl that the dosing
chamberthen be pumped by a licensed plumbec
E.Soil Absorption CeIL The discharge of sewage or wastewater to the ground su6ace is strictly prohibited due to the human health hazard
created by the efFluent.All taiWres crea[ed by surface discharge shall immediately be reported to the appropriate county.The pump shall then
be immediately disconnected to prevent further tlischarge to the ground surface via the soil absorption cell.The existing septic tank and
dosing chamber shail be used as a temporary holding tank until Ihe necessary repairs to the soil absorytion cell can be achieved.The
replacement shall be initiated only after any necessary plan approvals have been obtained from the
appwpriate plan review authority and the required sanitary pertnit is obtained from the county.
Project: Hermann Geomat Page 5 of 10
In Ground System Maintenance and Operation Specifications
Service Provider's Name Dan Burch Phone 715.416.1642
POWTS Regula[ors Name Sawyer County SPIA-Zoning Administration Phone (715)634-8288
Svstem Flow and Load Parameters
Design Flow-Peak 450 gpd Maximum InFluent Particle Size t/8 in
Estimated Flow-Average 300 gpd Maximum BOD5 30 mg/L
Seplic Tank Capacity 1000 gal Maximum TSS 30 mg/L
Soil Absorption Component Size 113.75 ft� Maximum FOG 10 mg/L
Type of Wastewater pomestic Maximum Fecal Coliform t0E4 cfu/100 mL
Service Freauencv
Septic and Pump Tank Ins ed and/or service once eve 3 ears
Effluent Filter Ins ect and clean as necessa at least once eve 3 ears
Pump and Controls Test once eve 3 ears
Alarm Should test periodicall
Pressure Sys[em 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
1. 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.March 20,2017.
2. Dispersal cell media conforms to GeoMat products approved for use with the GeoMat In Ground Component
Manual Ver. March 20, 2017. 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 soil erosion and help reduce frost penetration.
Laterol Tum-up Detall
6-8"Diameter Finished Threaded Cleanout
Lawn Sprinkler Grade \ Plug or Ball Valve
Box \
L
Lateral Ends at Last Orifice Where
Long Sweep 90 or Two
��45 Degree Bends Same
Diameter as Lateral
�Distribution Laterel � Lateral Cleanout
96.4 Feet
Project: Hermann Geomat Page 6 of 10
Dose Tank Information
Lockin,_ co�cr ��ith �c;irnin_ I;ih�l. �
locking devicc �nd ��'a�cr tight scal �
-r
�1" Vcnlyd Covcr _ f
Gicclrical lw�
as per N I:C 3 W j
and SPS 31G.28 �YA('i- I
. �
. .
�„_' i i_'_ I�mishcJ Gradc _ _ `d"�� -� �— -=�'1" 9��`_ �� � �_ . �. .1----
.. , • _ -- -
_ _ 12iscomiecl j
�" Cle:m oul Pipc I �i� � Optional ball ��il�r
Wircs I�rom I:I�ciric suurcr � , "� 1";� , to mntrol s�xtd of
___ � � cillucnt lnink duscd
� �
� �
Opiiunal o�tict
d" Inlct PSlliltcr
,,:,,,,� } � � _ 1 =_:,1 Forcemain diameter
I i;o,s siop I � . �, � i ��r�� �o�; ������� 1 .5 in.
and �catcr i�f-- �n�a.c �bn�ml�n omo �
� li �hl �Ssket �,, •�,lid�ruund ' i
� �+ �.,.� 1Y�Cp hok��r:�nl � {'UlIlCO
�, siphundc�i�z I
�
i I I i�h ���atcr alarm�r� 3�
IR k '
�
��f--hump On I'loat ��,! �, '
C r 1 u�
c�
Pump Ol�i I�loat'�� ', i , �' Pum off elevation ft
1 untp hr �---- P � )
� _ : 86.00
I isl,k�: �,
jj , i , �ttt:i Dose tank elevation (ft)
, Rcddin� undcr tanl���ii � ��'I»:? '� i??��� � � �.i� f---
�ii:; i„ < j� h .,,..,.,....,... ,,.,,,,,,,,,,,,,..,;;,, „ ,, it:,< . .. �, �. ;��n_, 85.00
Dimension Inches Gallons Wieser Concrete Products, Inc.
A 32.57 384.93 Capaci 600.00
B 2.00 23.64 Volume 11 .82 gal/inch
C 4.20 49.59
� D 12.00 141 .84
Total 50.76 600.00
� Filter Manufacturer Sim / Tech Filter
Filter Model Number STF 100 1/16 __�
, �ll �- _
� � Alarm Manufacturer SJE Rhombus
�� Alarm Model Number AB
1 �1� -
� Pump Manufacturer Zoeller Company
��a�""' Pump Model Number 152
�
� �p��/l �) ' Pump Must Deliver 15.00 gpm at 18.39 ft TDH
b
� �'� � Note: Switches containing mercury may not be used in this system.
Project: Hermann Geomat Page 7 of 10
GeoMat Distribution Cell Media Layout
3.25 Ceil Width(ft) 2.63 Sidewall to Lateral(k)
Distribution Cell Cross-section Arrangements
� _ S � _
b pOR @ . - _ _ .
O Distribution Pipe
GeoMat is covered with approved geoteutile fabric as per the their product approval.
Distribution Cell Plan View�ayout-Typical
3.25 Cell Width-A(ft) 35.00 Cell Length-B(ft)
End Connection Lateral Layout Diagram
_ __— _ _ _,
.�.. ..�. �. ,�... �. �..� .�... ..�. � ..� �, ...�. � �.. �.f;
�.. � � � .�.. � ...�� � �f
P �e
E':niehe.d(7r:�ric `�'V"� �V'V'`� �TYV'
I.` � �;-� :,:•..''�,. `' 12"-48"` .e.xtro` LtEettll.eve!
Sf�d Co.ar Teoommmaed '
pjpe Di,, ' ��„u ��`'�'���- . �f�Finfilba8ve
, " . _-I PWC �`___-::':
� ' - _— �� GEO MAr
I � 1 I � 1 2 ASTM.33�� � i � ' � ' � ' � Iafil�aative ScuSce
� - -_ �NATIVE�SOIL== -
_--_--- ___�
��_������_ — ' a+.itiay�F�cmr
See details on page 4 for number,size,and spacing of laterals.
Project: Hermann Geomat Page 8 of 10
CHECK BOX AS APPLICABLE. CHECK BOX AS APPLICABLE.
✓Q SOIL EVALUATION o s`��e: so 30 a5 so � SYSTEM PAGE 2 OF
SITE MAP PLOT PLAN
PROJECT NAME: �52 DESIGN FLOW: 4�JO GPD
Hermann Geomat Attach design flow calculations for commercial plans.
PROJECT ADDRESS: �SO�W TWltl Bay Ltl Pipe Material/ASTM Standard(Tables 384.303&384.30-5)
N sanitary sewer SCh 40 PVC �
BM Symbol: � BM Elevatbn: ��� � Force Main: SCII 4O PVC �
BM Description: f181I in 16" popple
Indicate north by IMPORTANT:
Siope Gradient(%) Well Symbol(If appiicable): � drawing an arrow Show ground elevation contours at suitable intervals.
. of TestedArea: - on theapproprlte-line.
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' "v� INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �.3 — �I �
Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(I)(m)]
Permit Holder's Name: ❑City ❑ Village Town of: State Plan Transaction ID#:
�alv'e. �f\�l�+A�h L,e Y1 n�o� �
Insp BM Elev: BM Description: Parcei Tax No:
l o�.o ' N9�1 �� Lb., ����� � ti -9'Y� _3� �30�
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic � _ (oap Benchmark IpO,c�'
Dosing ^c.,,,�.�riv �po
Aeration Bldg. Sewer �p,� �
Holding St/Ht Inlet Qp,S"�
TANK SETBACK INFORMATION St/Ht Outlet .�.
TANK TO P/L WELL BLDG vENTro ROAD Dt Inlet
AIRINTAKE
Septic �. � }{�` '� .}- � NA Dt Bottom �.S$ �
Dosing K ti � � NA Installation
Contour
Aeration NA Header I Man.
Holding Dist. Pipe �'J q �
PUMP 1 SIPHON INFORMATION Infiltrative �6`y,�
Surface
Manufacturer Demand Final Grade
Model Number � GPM C-,3 �� }�
TDH �,'�,. Lift Friction Loss Sys Head TDH Ft
Forcemain L �� Dia �� Dist.To Well
DISPERSAL CELL INFORMATION
DIMENSIONS �N � ' L #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav Conv ❑ Aggregate 1�1,�
P/L Bldg Well o� IGP ❑ Chamber �`�14
INFORMATION Waters � AG � EZFIow Model Number:
CELL TO -- �-_ 161---_._(�Y t�__ ❑ Mound � Other _
-- __— - - __-- __- - - ---
DISTRIBUTION SYSTEM X Pressure Systems Only
— —
Header I Manifold Distribution Pipe(s) ; X Hole Size X Hole Observation Pipes
Length Dia Length Dia Spac j � Spacing ❑Yes ❑ No
-- - - --- _.- _
SOIL COVER
— — -
Depth Over Depth Over Depth of Seeded/Sodded Mulched
Cell Center Gell Edges i Topsoil ❑Yes ❑ No �❑Yes ❑ N�
COMMENTS: (Include code discrepancies, persons present, etc.)
��„s�,.�l�( i�-f�� (�3
Plan revision required?❑Yes 0 No �3 I�J ',, ` � /' / �
I 1r'�1 I � -- I, C��� � 10
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
A�OITIONAL COMMENTS ANO SKETCH
SANITARY PERMIT NUMBER ____�3^�� I_ ____
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