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Home My WebLink About026-939-11-5311-SAN-2023-245 '"�" `"`� Department of Safety c°°°�' � = \� = & Professional Services '� � � � �- � �� - � Sanitary Permit � er(to be filled in by( ,,, = Industry Services Division � �.,_ -�� C� S 1 � 3�� w Sanitary Permit Application State Transaction Numbcr � In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form ro the appmpriate govemmental unit � is required prior to obtaining a sanitary pemvt.Note:Application forms for state-0wned POWTS are submitted to Project Address(if different than mailing ad� the Department of Safety and Pmfessional Services.Personal information you provide may be used for secondary ,�/ purposes in accordance with the Privacy Law,s. 15.04(Ixm),Stats. �� (�� vV �� I.Application Information-Please Print All Informatioo Property Owner's Name Parcel# ru.�� d�k�._c.�i/-5�t� Property Owner's Mailing Address Property Location ` ��1 �`f• G��t� City,State Zip Code Phone Number � � �,1 �(.� �� Section 1__ W � II.T of Building(c6eck all that apply) Lot# � T � N R E o � 1 or 2 Family Dwelling-Number of E3edrooms f-� Subdivision Name Block# ��" ❑Public/Commercial-Describe Use ^ ❑City of ❑State Owned-Describe Use CSM Number ❑Village of '�'I� ��b �Town of ��,��.K �h-G Iit.Type o[POWTS Permit:(Check either"New"or"Replacement"and other applicable on tine A. C6eck one box on line B.Complete line C if a licable.) A. ❑ New System �Replacement System ❑ Other Modification to Existing System(explain) ❑ Additional Pretreatment Unit(explain) B. (�-Holding Tank ❑ In-Ground ❑At-Grade ❑ Mound ❑ Individual Site Design ❑Other Type(expiain) (conventional) C• ❑ Renewal Before ❑ Re�•ision ❑ Change of Plumber ❑ Transfer to New Owner �st Previous Permit Number and Date Issued Expiration N�� IV.Dispersal/'I'reatment Area and Tank Information: Design Flow(gpd) Design Soil Application Rate(gpd's� Dispersal Area Required(s� Dispersal Area Proposed(s� System Elevation �� _ �� Capacity in Total #of Manufacturer Tank Information Gallons Gallons Units � o '� � New Tanks F�cisting Tanks y � � � y p � � 0 a` U v� ti v, i,. C7 P. Septic or Holding Tank y�/�,,n ' �m� r �r/ ' e � � Dosing Chamber V.Responsibility Statement-I,the ondersigned,assume responsibility for instsllaHon ot t6e POWTS shown on the attached plans. Plumber's Name(Print) Plum ' Signature MP/MPRS Number Business Phone Number �i .�(-l''� � .__ ___ G'��4/ 7i5-,ss�'s i�� Plumbe s Addtess(Street,City,State,Zip Code) � � n� �" �f�x-� � , � 5`� VI.Count /Department Use Only �Ap �� ❑Disapproved Permit Fee Date lssued lssuing Agent Signature ❑Owner Given Reason for Denial $ ( 6 D'� � I'�� I�� ' "1��I'"�/l.l�.�- Conditions of Approval/Reasons for Disapproval �-a �3 _ _ � � � i �3ate � __.__..� � �� ' 6 2023 �r� 2 :hk# aa-�� SEP C� ^ la� �G�,��?��, _ _ SAWYER COUNT`( �v Zp{�}(^„qpMIN1STRATaON Attach to complete plans tor the s��stem and submit to the County only on paper oot less than 8 tn x 11 inc6es in size ��,��t� NO R`FfJN��AF7ER SBD-6398(R.03/22) IS.ci11E OF P'�R,�li1� Sawyer County Zoning & Conservation Administration �� 10610 Main Street, Suite 49 � �y� c� 1� Hayward,Wisconsin 54843 '�. '" '��fi l� (715)634-8288 ��%� � � FAX(715)638-3277 \�I �� ,_ - __ 1�� www.sawvcrcounlveov_p� � ol � io / E-mail:sanitarian(n�sawycrcountveov.ore I �� ' i � Toll Frcc Courthouse/General Information 1-877-699-4110 �I��y..;;t:y i�� j�\oN�� Holding Tank Approval Checklist I. Sanitary Cover Sheet: Date Stamp V`� / a� / �.3 Parcel ID# o � � - R 3 °� - � � - S.3 ( � II. Plot Plan: XProperty Lines � Benchmark BM ♦ � Site Address p(North Arrow � Structure � Scale �Well �C< 25' to Service Road �Legal Description ➢Q�Iearest Road Intersection �Setbacks to: Property Line, Well, Structure, Water bodies, Roads III. Required Plans: � Index Page with Original Signature DC Manageinent Plan/Contingency Plan Servicing Contract Holding Tank Agreement Form ($30 to ROD) IV. Holding Tank Specifications: �Tank Cross-Section: Manufacturer: wte'S� Gallons: 3� (�� Tank Anchor Calculations [SPS 383.43 (8) (g)] �Locking device, chains/locks �Alann, electrical per SPS 383.43 (8) (e) �3'" Bedding Material < 1/2 " V. POWTS Component Manual Reference: �Holding Tank Version 2.1 (May 2022-2027) Owner: ��„�� Plumber: �+w� Application Review Date: `� �2-9��3 POWTS Reviewer: �� ,�J�� Name (��I�,l(o Rev. 4/27/2023 Credential# PAGE 1 OF 4 Holding Tank Plan Index 8� Cover Sheet Component Manual Design References: Holding Tank Version 2.1 (May 2022-2027) Pg 1 of 4 Index&Cover Sheet Pg 2 of 4 Plot Plan Pg 3 of 4 Holding Tank Specifications Pg 4 of 4 Management Plan Attachments: Enclosures: POWTS Application for Review Soil Evaluation Report&Site Map(if applicable) Holdin Tank Pum in Contract if a licable) Holdin Tank A reement if a licable Project Name/Description Owner Name(s): ��i,�lYU l �T. l�/'�;�G'-G:'��f? Phone: - - Owner Address:�2��1 �" �/��uilXl� G11.� Z�p: �J y�13 Project Address: J 7��//10�,�(/E �4,l� �/'�' ' l��7� Govt.Lot:�_ 1/4 of 1/4,Section�l ,T�_N-R � E Q or W� Township: C a �� County: .�L(LUZf�� Project Parcel ID#: ��(D��f—ll— '~7 3�� Designer Information Designer Name:�/�/�I �l'�Ip1lX / Phone:�S�- n%73 Designer Address:�",��j,�i/�17�1 YZG�'�� Z�P� ��3 E-mail: �lfU��L��i.�L License Number: /C��/� Remarks: Signature: ---- Date: ��3 Onginal sig re required on each submitted copy. � -, _�( _� � n ! �"�:.i�� • — : " [.cr �WY �Sy►' G� "� � ��`�3� ��C%�'� �►�UlcS t �C?iWt/�'i+ l...Q� � S �.�- '.#�.�-f� J G(� P� ,� l 5�I�7 F� � ,t--�� -� �i : d � -�3��--��'�- ��1 �� /�/G/.�'.f�'L� f ��, �� `� V�� Ls'� � V • i � ! � � t � � �� S !t� ; � �l�C7 v� 1n1 �,{TL�,N,r�K.,� t-r'(,tlt.� � t�) ; ___, � �Q�1\ �j rJ Cv 2m 30 yL' _-._..�--___._.._._��.__. _ _ .„� .._.. ..___- .r-- __ _ -�—".._ ,_. _�_.. ._.._._.._.a._,.",__._..`._...._.._..... # , N �� . t, ,��---------__—# 0�� ,�e, ; a�, e 11 . � L.�-_<.--�,._ J _ , .. , � , +'` �� 1 3 � � - ._� �C3 f� �``'� `,., ;cx.:F� �I J � � f ':'�Oc? .r�u � �'� � � ttd`:GSd✓` € L_�..f.i t , & ; , � #��o:�t'�� . ��b t � �- 4'l'I"�t�''' ,al j' } q7. c�0 �n11e.7''' Q�' ,�,°''�. �-�� ",. ( ; ; � � ; i ( ' � � F . 1 i �! i i � i � � , ; � 3 � ' �} 1 . ; � � � � �._._.._ __._...___—.__--------. __.______ J � � � f I � � �'f — f f� u�y � PAGE30F4 HOLDING TANK SPECIFICATIONS (No Scale) Weatherproof 72"Min.or 2.0 ft above Junction and APPro�� Established Flaod Elevatlon Alartn Box (�YP��) Vent Cap ElecMcal must comply with q SPS 316 and NEC 300 4"0 Vent Pi pproved Locking Manhole PE with Waming Label Attached �Conduit >70 ft from (typical) 4"Min.or 2.0 tt above Building � Esfablished Flood Eleva6on (rypicaq -- �AirfightSeal " 1 __ Finished Grade 18"Min. (�YPical) .. � � ' Inlet Inletlnvert �Watertight Approved Joints with Plug Apprwed Pipe 3 ft onto � Max.12"or 90%ot total vdume Solid Gmund � if more than one tank a Alarm-0n HOLDING TANK VOLUME= 3< < <l O gal e 3"Approved Bedding Material Beneath Tank TANK MANUFACTURER: Gf/,'P S�✓ Anchor tank as necessary pursuant to SPS 383.43(8)(g) Ballast Weight=[(cu.ft.tank.vol x 62.4 Ibs/cu.ft)-Ibs.tank.wt]x 1.5 Ballast Weight=[(�cu.ft.x 62.4 Ibs/cu.ft)- 22.3/� Ibs]x 1.5= 33 �/G�,Ibs � D N 60a ns 102" � � REQD m 48„ z ; r Z I c,i � � I � i n � C A I � uP a�" I I `� � � A --+ J ° 0 4,. CAS \ -� D � Im � m � -� � � � n � 3„ 51�„ 6„ N m m y x r n r�i � � o p O D m � N � � I � � � �+-� i*� - n � � ry 43" N � A J - r .� m --i C7 f*1 D m D O �t '� � C � � "i � � � I D � UP 45" i z 4" CAS � � � A I N 'I � � l ` r � / � � I O C 46" � Ti � C D O D r = r Z Z � � rn -*i o •'� � m� z �o o � � -�''i i m -� � � X � � Z � � � cZi � ^pc�nZ �'_Zm �� Z �Z� oDa D C � px = m � CmD D m� � D � = ZZOg � -�i == � pr � Z � � m � O m � � � � � AZp Np � z � r _ 2 �0�� v v n � � Z � � cC1S Z n = .. { �Zr�*� Drr*� O � � mmN �° om�= �"'_ � � O o a m " n u � tn Z � p � r D -i � � < cnwr"� `a I A m "� � � ao m -i v� • m : .�� p °w D n � m °' � W Z `°�w � D o c� � � �mm m Amoo � Aoo�- -�c � � o r*, z o � .-, v cn : -� r �+ �, � o o c"v':' a =o C7 O O D 3 N N.. C { C v (n p � cp .� � � _ -Di { o m � H n � O v z � � m� rn oD u �� O �� N � � �+ D D O � p �� — � �„ -- •• -• •• Z Z � ''� O D � � � nrD O O � � m - � TI � m � � � \ x z -� � c� a '� m c o z D�co W , � n D � � m� � D � �o -�, � N �o -�i —I � A = � D � m � � — D m v Z � O A � �W 0 O I � m � Z D �m n z � H A � � r NN m � I � � r � Z Z � � � I � m � � m : � � = WLP3OOO �RAWN BY: SME SCALE: 1 4"=1'-0" PRE-POUR: � � WIES COIICAETE REV. �+ � SEPTIC MANUAL DATE: JANUARY 2011 OATE: . FCST-POUR: � Z W37t6 US N\YY 1C MAtDEN ROCK, �til 54750 \ � REVISED JAN. 2011 800- 325-8456 FiLE: MP30'JO PAGE40F4 Holding Tank Management Plan IMPORTANT: The owner of this holding tank(s)shall be responsibie for its perpetual operation and maintenance pursuant to requirements of SPS 382-384,Wisc.Admin.Code. Pursuant to SPS 383.52(2),Wisc.Admin.Code,this holding tank(s) shall be considered a human health hazard if not maintained in accordance with this approved management plan. Furthertnore,all inspection and maintenance activities shall be perfortned by a registered POWTS Maintainer in accordance with SPS 383.52(3),Wisc.Admin.Code. Estimated Daily Wastewater Flow= �n� gpd Inspection Checklist INSPECT EVERY 3 YEARS o type of use o age of system o nuisance factors(i.e.odors,user complaints,etc.) o mechanical malfunctlon(i.e.,pumps,valves,switches,floats,etc.) o material fatigue(i.e.,leaks,breaks,corrosion,etc.) o neglect or improper use(i.e.,exceeding design capacities,prohibited activities,etc.) o electrical components(i.e.,wiring,connections,switches,controls,timers,alarms,etc.) o surtace discharge of effluent or sewage back-up into structure served SERVICING FREQUENCY o The tank(s)shall be pumped by a certified septage servicing operator licensed under s.281.48 Wisc.Stats. when the wastewater in the tank(s)reaches a level of one foot below the inlet invert of the tank(s). Disposal of contents shall be pursuant to NR 113,Wisc.Admin.Code. Tank pumping reports shall be submitted to the proper local govemment unit in accordance with SPS 383.55 Wis. Admin.Code. Report any component failure or malfunction to: Name of individual or company:��Yl J`f!CL�� Phone:7(5'S��[�/�� Local government unit: Phone:�/S -�7��f""J �O Local government unit address: �� IP: J'G a�Z� Any defective part of this system shall be repaired,replaced,or removed pursuant to SPS 383.51(1),Wisc.Admin. Code.Repair or replacement of failed or malfunctioning components shall comply with SPS 383,Wisc.Admin.Code. No product for chemical or physical restoration of the POWTS may be used unless approved by the department in accordance with SPS 384,Wisc.Admin.Code. Contingencv Plan In the event that any failed component of this holding tank(s)cannot be repaired,it shall be replaced pursuant to a plan submitted to the appropriate agecy for review and approval. Svstem Abandonment If use of this tank(s)is discontinued,it shall be abandoned in accordance with SPS 383.33,Wisc.Admin.Code. I�OLDING TANK SER��ICING CONTRACT Contract Date: /�'/ _��3 � This contract is made beh��een the Holding Tank O�i�ner and the Pumper. Holding Tank Ov��ner's Name: Parn er's N le: . �l'�� --�; �i��SO/�/ j �E,�.c-� � �� , � ; Parcel Identificadon i�`umber: , � (12 Digit Le�acy ID) � '�2 (� - J�� - �� - ,�-�"� � � � � 1 . The ownr,r agrees to file a copy of this contract u�ith the governmental unit, Sawycr County, �uhicil l�as accepte� and recarded �srith the Office of the Register of Deeds, the R�aintenance A��eement for a Holdin, Tank required under the Sawyer County Private Se�va�e System Ordinance for the issuance of a Sanitar_y Permit for the installation of a holdinQ Yank(s). ?. The owner a,rees to have tl�e I�oldin� tank(s) sen•iced by thc pumper and guarantees to permit the pumper to have access and to enter upon the property for the purpose of ser��icing tlie liolding tank(s). Tlie owner a�recs to maintain the all-�veather access road or dri�,e so that the pumper can service thc holding tank("s) «�ith die Eiumping equipment. The owner furtller aarees to pay the pumper for charges incurred in ser��icing the holding tank(s) as mutually a�reed upon by the o�vner and pumper. 3. TI�e pumper agrees to submit to tlie Governmental linit, Sa�vyer County, a report for the servicing of thc hoiding tank{s) as required under SPS 383.55, ��isconsin Administrative Code and fhe Sawyer County Private Se�va�e System Ordinance. The pumper fiirther agrees to include the following in the report: a. The name and address of tl�e pe�•son responsible for- se�-��icin� the holding tai�lc; b. The name of thc owner of the holdin, tanic; c. Tl�e site address of the holding tanlc; d. The date the holding taok �vas scrviced; e. The volumes in gallons of tlie contents pumped from the holding tank for each servicing; f. The disposa( sites to ��rllich the contents fi•om the holdi�l� tank were delivered. 4. Tt�is agreement �vill remain in effect until the owner or pumper terminates this contract. In ti�e event of a chan�e in this eontract, the ov��ner agrees to file a copy of any changes ta tl�is ser�=ice contract or a copy of a new sei-�rice co��tract �vitt� Sawyer County within ten (I O) business days f►-om tl�e date of change to this ser�rice coiitract. Owner's Name: (Print) O�'iizi''S S1�Ilatlll"E' Onh• one o�vner signature required) I �A-�r� -s �No�+�� .- ,,;� C - { � � f Pumper's Name: (P�-int) � Pumper's Sianature: . P��r.� -- (�; �s i � r�i'� �'? �.`-� � �� `��.Z -,�� ' Pumper's ReQistration Number: `"��g� [ �-- � tze��. o;,,s%�; �°w� "�� li � ` � � ��I II�IIIIII ��I I�IL,II �� {a`o�`�"3 ��s ��c�r�:8`��'4�1� Document Number pocument Title TX:QQ�r't�$ $4��d� PAULA CHISSER REGI�T�1t�F DEE�S SAWYER C�UNTY, WI 09/29J2Q23 1�:58 AM RECORDITlG FEE 30.00 PAGES; � Recording Area Sawyer County Zoning Dept. 10610 Main Street, Suite#49 Hayward, WI 54843 oa�,��3R - ll - S"31� Parcel Identification Number(PIN) THIS PAGE IS PART OF THIS LEGAL DOCUMENT—DO NOT REMOVE. This information must be compieted by submitter: document title name&return address,and PIN(if required). Other information such as the granting clause, legal description,etc.,may be placed on this first page of the document or may be placed on additional pages of the document. WRDA Rev. 12/22/2010 - USE BLACK INK ONLY- POWTS MAINTENANCE AGREEMENT For Holding Tanks Owner's Name(s)as shown on deed: \`�� /�, ., .` FZ�:Y A•...MD ��. � �, ._" " -�S� N �y S�f- ;��• ��.�,�. Parce Identification Number: ,� ��'• � . (12DigitLegacylD) (,i ;��-��'� 1 '��1� -�:' NOTARY �:�� — _ ^e`� :z't— Legal Description of Property: � PV B L I C � -SEE ATTACHED SHEET - , ' � :s�;•. .�'��' : �9T�c'••.... ••'%.C�� We acknowledge that application is being made for the installation of a holding tank(s)on the /� Cr` ,ti� �G`� �� property described on the attached sheet. ��/ � � � � 1�� Return To:Sawyer County Zoning and Conservation Administration 10670 Main St.Suite 49,Hayward,WI 54843 As an inducement to the County of Sawyer to issue a sanitary permit for a holding tank on the above-described property,the owner is responsible for the operation and maintenance of the holding tank, locking device,alarm and access, and agrees to conform to all applicable requirements of SPS 383,Wis.Adm. Code relating to holding tank management, including the following: 1. The owner agrees to contract with a person who is licensed under Ch. NR 113,Wis.Adm.Code, except as provided by Section 281.48(3)(d), Stats.,to have the holding tank properly serviced and to file a copy of the service contract with the governmental unit. The owner further agrees to file a copy of any changes to the service contract,or a copy of a new service contract,with the governmental unit within ten (10)business days from the date of change to the service contract. 2. The owner agrees to contract with a person licensed under Ch. NR 113,Wis.Adm. Code,who shall submit pumping reports to the governmental unit in accordance with SPS 383.55,Wis.Adm.Code,for the servicing of the holding tank. In the case of exemption under Section 281.48(3)(d), Stats.,the owner shall submit the report to the governmental unit. The governmental unit may enter upon the property to investigate the condition of the holding tank when pumping reports may indicate the holding tank is not being properly maintained. 3. If the owner fails to have the holding tank properly serviced in response to orders issued by the governmental unit to prevent or abate a human health hazard as described in Section.254.59, Stats.,the governmental unit may enter upon the property and service, or cause the tank to be serviced. Pursuant to Section 145.20(4)Wis. Stats., a governmental unit may assess the owner of a private sewage system for costs related to the pumping of a septic or holding tank.The charges will be assessed as prescribed by Section 66.0703, stats. The owner agrees to pay all charges and cost incurred by the governmental unit for inspection, pumping, hauling,or otherwise servicing and maintaining the holding tank in such a manner as to prevent or abate any human health hazard caused by the holding tank. 4. This agreement will remain in effect only until the governmental unit responsible for the regulation of private sewage systems certifies that either a soil absorption system that complies with SPS 383,Wis.Adm. Code, or a municipai sewer serves the property. In addition,this agreement may be cancelled by executing and recording said certification with reference to this agreement in such manner which will permit the existence of the certification to be determined by reference to the property. 5. This agreement shall be binding upon the owner,the heirs of the owner, and assignees of the owner.The owner shall submit the agreement to the register of deeds, and the agreement shall be recorded by the register of deeds in a manner which will permit the existence of the agreement to be determined by reference to the property where the holding tank is installed. -Oni one owner si nature required- ACKNOV�ILEDGMENT Ow r's Signature� `1 State of: �'� `� � ,,.� j � i �1'�� _�i �� 2 �ti��'� County of: q W �� Owner's Name (�'rint): Subscribed and sworn to before me on this �' � � L'1�" �(� 1 �_day of 4��.i�l US� � 20� � Date: �, By(Owner's Name): "= ' � i� � �� -��%�_� Notary Public Signature:-- �� ` �� - Drafted by: Public Notary Name (Print): '� �ti�� +�'� "�; , � � �� — ` ;�� My commission expires on: �,' ��:,�� Personal information you provide may be used for secondary purposes[Privacy Law,§15.04(I)(m)] Rev.03/26/13 That part of Government Lot Three (3),Section Eleven (11),Township Thirty- nine (39) North, Range Nine (9) West and described as Parcel A of CSM 228, in Volume 2 of Certified Survey Maps, Pages 14 and 15 as document number 138415, located zn the Town of Sand Lake, Sawyer County, Wisconsin. 9/5/23,8:59 AM Novus-Wisconsin Access rev. 13.1108 Real Estate Sawyer Counry Property Listing Property Status:Current Today's Date: 9/5/2023 Created On: 2/6/2007 7:55:47 AM �Descripdon Updated: 5/1/Z020 � Ownership Updated: 8/15/2019 Tax ID: 28196 BARBARA 7 ANDERSON TRUST HAYWARD WI PIN: 57-026-2-39-09-11-5 OS-003-000110 Legacy PIN: 026939115311 8illing Address: Mailing Address: Map ID: :3.11 BARBARA]ANDERSON TRUST BARBARA 7 ANDERSON Municipality: (026)70WN OF SAND LAICE 15997 FIFTH ST TRUS7 STR: Sll T39N R09W HAYWARD WI 54843 15997 FIFTH ST Description: PRT GOVT LOT 3 PCL A CSM 2/14#228 HAYWARD WI 54843 Recorded Acres: Z,270 Lottery Claims: 0 w Site Address * indicates Private Road First Doliar: Yes 14902W COUNTY HWY E STONE LAKE 54876 Waterbody: Lac Courte Oreilles Whitefsh Creek Zoning: (A-1)Agricultural One -� Property Auessment Updated: 9/28/2017 (RRl) Residentlal/Recreatlonal One 2023 Assessment Detail ESN: 423 Code Acres Land Imp. Gl-RESIDENTIAL 2.270 402,900 48,800 �� Tax DistricCs Updated: 2/6/2007 2-YearComparison 2022 2023 Change 1 State of Wisconsin �nd: 40Z,900 402,900 0.0% 57 Sawyer County Improved: 48,800 48,SOD 0.0% 026 Town of Sand Lake Total: 451,700 451,700 0.0% 572478 Hayward Community School District 001700 Technical College + Recorded Documents Updated: 12(28(Z018 ��roperty Nistory O QUIT CLAIM DEED N/A Date Recorded: 8/2/2019 419133 O TRUSTEES DEED Date Recorded: 8/2/2019 919132 O WARRANTV DEED Date Recorded: 9/23/2004 325261 O WARRANTY DEED Date Recorded: 4/28/1972 140109 O CERTlRED SURVEY MAP Date Recorded: SO/11/1971 138415 https://tas.sawyercountygov.org/Access/mastecasp �� F,. �. �r t 2 ' � < a��"}� , c 1 � , .' �, : - ;" • i5i5 � ' . -�) '� � _ '� . �: , > -. - � � i• � � . � t ' � .� 'r— _, � oys ,�.. .4�' �` ; -' ,.� -- �. � � �L�` -: Y � .'�� . :r m'�'~ �{` ,'•'�.�, ~-� .t.r. j� a-� :.�. ` . § 7: � ' + , �•. -*" .x i ' �-.' . � �l '. t � �t y .��;, Y �K YI-_ '� ��—�_._\ .� ! .r A � �� t� }w „+ , � 1'�.� : � t(. � 1�'. .S r �., �' � 4 , � F' ' 1 � �5 s,g.j5 r ..�� r '� x f - f+ �l� � _ ' .,� •3.ti'. �� Y� G .- e.3 � ,�. _ .- -�`�t •---y. �v 2 ��,y, T �� ; . �_ - -S�` ' _ r . ,�, 1'� ` :z. � 5 k��. �� -,�.� �. 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J�� ;.:�� . 1� 'w �'y'�: v:��- �'�� ii C^�� f . .R . . x C� .� . . a.. - . t�F l�f�. - '1..., s` � ��- /� � � > �'� T�`.v,' � ....._ {��• /«� �, ry � • � lY �� , � yu {,'it a �• �l. ,� �, �' . �A �/T�'n �� i �., �• �a.• � . i J h,� \„_J � y<� �� ." Ffi ' �fT' � • � ly��'i ��,� . - .. � _ r r ' � \ r � � � � r. D� Y �� '� • .'.s�. 3' '� �, � 'r.,� �4 � a�'- . �. . , .� :I � �y�� . � ' �' .. c'�, �r,��CNh-`•,.._..� .. .. - - '? ��< af� . � �� ,7�,[.�� xL'� -�s.�. ..5 d'�� . � �_� � - '�� ' �� ' _. � ��""T'"�� PRIVATE ONSITE WASTE TREATMENT County �� o$ � SYSTEMS SaWyer ..<�� ps '�' ( POWTS) <� ,� H( L- �%/ ' �-y' INSPECTION REPORT sanitary Permit No: Safety and Buildings Division (ATTACH TO PERMIT) GENERAL INFORMATION ��— 2c.�s Persvnal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(1)(m)] Permit Holder's Name: ❑City ❑ Village Town of: State Plan Transaction ID#: �cr+t �. �M8� J�`�l�C �Ks� r-- Insp BM Elev: BM Description: Parcel Tax No: ' `iV'�r � O� �� -('l�„f.r- �� t/v\O�� -(� r�/ � I TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV Septic Benchmark ��,o � Dosing Aeration Bldg. Sewer Q$• Holding �,�„Q,�� 3�csz5� St/Ht Inlet g6,$ TANK SETBACK INFORMATION St I Ht Outlet TANK TO P/L WELL BLDG vENuo ROAD Dt Inlet AIR INTAKE Septic NA Dt Bottom Dosing NA Installation Contour Aeration NA Header/Man. Holding ,�,5� fi� �.$3� �Yb G2S' Dist. Pipe PUMP 151PHON INFORMATION Infiltrative 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 W L #of Cells Type of System Distribution Media Manufacturer: SETBACK OHWM of Nav ° Conv ❑ Aggregate INFORMATION P I L Bldg Well Waters a IGP ❑ Chamber ❑ AG a EZFIow Model Number: CELL TO ❑ Mound o Other — _ _---__ — ___ --- --- -- _ -- -_- - _ DISTRIBUTION SYSTEM X Pressure Systems Onry -- -- - -- ___ — --_ � Header/Manifold Distribution Pipe(s) X Hole Size , X Hole Observation Pipes Length Dia Length Dia Spac _ I Spacing ❑Yes ❑ No SOIL COVER — --- ---� _. _- — --- Depth Over Depth Over Depth of - Seeded/Sodded Mulched � Cell Center Cell Edges Topsoil � ❑Yes ❑ No � ❑Yes � No COMMENTS: (Include code discrepancies, persons present,etc.) ��//-�� Y��3 � � � �� - �� - Plan revision required?�Yes ❑ No �3��'a�� . � � Use other side for atlditional information Date POWTS Inspector's Signature Certification Number SBD-6710(R.3/01) A�OITIONAL COMMENTS ANO SKETCH SANITAAY PERMIT NUMBEA: �3 ^2�{� �--- ��v C,1�, �_ � — - a 4� S� � I� O � I � l 7-�1 �^�� l �� O� � V'�,h� 1 I �►� }2s � � � — �Q�. �i�- � S e � — 3� �� {f �� \ � �� ,t�ci c�• eo'c�'�-�-�,�