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Home My WebLink About020-638-04-2406-SAN-2023-250 ' Department of Safety c°°°ty � � � � & Professional Services, ��-r � a _ Sanitary Pe mit Number(to be filled in by G p= , Industry Services Division _ (�S I �� -( � � State Tiansaction Number � Sanitary Permit Application � In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit.Note:Application forms for state-0wned POWTS are submitted to Project Address(if different than mailing add � the Departmeot of Safery and Professional Services.Personal information you provide may be used for secondary G-'1 r�y`,` u jG'��j..a�( �1 ��„ putposes in accordance with the Privacy Law,s.15.04(l)(m),Stats. '+� � 1 ! �Y �Yi l 1 I.Applicatioa Information—Please Print All Information ,S � Property Owncr's Namc Parcc # ' E.� Q�l � � r Q�O � �� Property Owner's Mailing Address Property Location F ��-'�`'� ��- City,State Zip Code Phone Number NE.Sw d' N'^�sw �'s�'"N 5 i t S `l �� —��<, j�iN_v4, se�t�an_�_ II.Type f Building(c eck all t6at apply) Lot# T N R E or�c I�1 or 2 Family Dwelling—Number ofBedrooms � Subdivision Name � �_ � Block# ❑Public/Commercial—Describe Use ❑City of _ ❑State Owned—Describe Use �� CSM Number ❑V illage of �7/I l�Y �#�n'j 3 �To,�,oe o��bwc, III.Type of POWTS Permit:(Check either"New"or"ReplacemenP'and other applicable on fine A. Check one box on line B.Complete line C i a licable. `�' New S stem ❑ Additional Pretreatment Unit � y ❑ Replacement System ❑ Other Modification to tixistmg Systcm(explain) (explain) B. �Holding Tank ❑ In-Ground ❑ ;At-Grade ❑ Mound ❑ Individual Site Design ❑Other Type(explain) (convcntional) C• ❑ Renewal Before ❑ Revision ❑ Change of Plumber ist Previous Permit Number and Date Issued ❑Transfer to New Owner Expiration IV.DispersaUTreatment Area and Tank Information: Desi�n Flow(gpd) Design Soil Application Rate(gpd/sfl Dispersal Area Required(s� Dispersal Area Proposed(sfl System Elevation a� r�� Nn n Capacity in Total #of Manufacturer Gallons Gallons Uuits � v �„ � Tank Infortnation � � y New Tanks F�cisting Tanks y o o; � y p �o c`"y w U �n �, cn i.�. C7 0. Septic or Holding Tank � r r � � � Dosing Chamber `Ts� V.Responsibility Statement-I,t6e undersigned,assume responsibili for installatioa of the POWTS shown on the attached plans. Plumber's Name(Print) Plumber's Si�mature "� MP/MPRS Number t3usiness Phone Number � h �. Plumber's Address(Strcet,City,State,Zip Codc) U U - r YI.C n /Department Use Onl �A�ro4 ❑Disapprvved $ermit Fe� Date Issued Issuing Agent Signature �y� �{Od. I C�.� � :�3 -��utZQc J�-Zw� ❑Owner Given Reason for Denial Conditions of Approval/Reasons for Disappmval r,r � r�jr� s` ��f �� " --� --J�- � _ � � ��! �� _�� c a ' Fr_ - � _,� �� s Zo23 , Tn ' k# �`��-----'"_.__ _ SEP 2 C.s I / `�� l- ��h � S�`��`dY:� �"C_:��>,�.-:;-, '�'G` 3�� . '": � ' , ZONING ADM{�lSTRATlON Attach to complete plans for the system and submit to the Couoty only on paper not less than 8 lrz=I t inches in size ,�U�S � NO R�F�JN�S qFTER SBD-6398(R 03/22) IS��U��J,'(' Sawyer County Zoning & Conservation Administration 10610 Main Street, Suite 49 ��1� Hayward, Wisconsin 54843 -l�R C� ��/ ��C� � (7i5)634-8288 � �� FAX(7I5)638-3277 �Z I .Q� `�i �� - I�/ wwwsawyercounty ov.org _ I � E-mail:sanitarian(n?sawycrcount ov.org I o�-�\�.'�i�� Toll Free CourHiouse/Gencral Information I-877-699-4110 �I�L -_'"y `c�_ ��j�`ON�� Holding Tank Approval Checklist L Sanitary Cover Sheet: Date Stainp �� / �$ / a��-� Parcel ID# ��0- 6 3� _c� �{ _ 2� O(� II. Plot Plan: �Property Lines /Benchinark BM ♦ l71' n�r- I,�� Site Address �CNorth Arrow �Structure l< Scale �Well /�<25' to Service Road �Legal Description �Nearest Road Intersection Setbacks to: Property Line, Well, Structure, Water bodies, Roads III. Required Plans: �Index Page witli Original Signature D� Management Plan/Contingency Plan Servicing Contract _Holding Tank Agreement Fonn ($30 to ROD) IV. Holding Tank Specifications: � Tank Cross-Section: Manufacturer: �� Gallons: �2�'(�� 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: S��S le--� Plumber: �, ��"�' � Application Review Date: �� (o�-`i l e20�—� POWTS Reviewer: ��•.��2� Name /�, � C�� Rev. 4/27/2023 G�edcntial# PAGE 1 OF 4 Holding Tank Plan Index & 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 NA 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): Michael and Kae Shisler Phone: - - Owner Address: 522 Fritz Ave.W Ladysmith,WI Z�P;54848 Project Address: 8777W Whltet211 CifCle Ojibwa,WI 54862 Govt.Lot: SE �1/4 of NW �1/4,Section 4 ,T 38 N-R 6 E❑or W Q✓ Township: Ojibwa County: Sawyer Project Parcel ID#: 020638042406 Designer Information Designer Name: Kurt Brown Phone: �15 _943 2988 DesignerAddress: W10487 Old Murry Rd Exeland,WI Z�p: 54835 E-mai�: brownk@bevcomm.net _. „ License Number: 224281 Remarks: ' Date: Q�/��:�3 Signature: ' Li � �� Origina signature required on each submitted copy. � PROJECT ASOILTEST WAS NOT DONE ON THIS SITE. OWNER ELECTED TO HAVEA 1,200/750 COMB.TANK INSTALLEDAT THIS MICHAELAND KAE SHISLER TIME AND MAY HAVE THE SOIL EVALUATED FOR A MOUND IN 8777WWHITETAILCIRCLE THEFUTURE. THETANKHASATOTALCAPACITYOF2,165 OJIBWA,WI54862 GALLONSWHENUSEDASAHOLDINGTANK. SITEISCOMPLETELY UNDEVELO DASOF9-12-23. TOWN OF OJIBWA L.�� SE, NW,S4,T38N, R6W SIGNED: LG�/��"�'��I �v�l—�� s�, ��I I 6� #��3 WHITETAIL CIRCLE #8777W � �H,el� -}^� w.��"' N �� SCALE: 1"=40' PROPOSED (� � 2 BR HOUSE � �K \ 1 �/y o.� %� �7"�� i J�� ai,2oonso � ----� COMB.TANK P/L P/L LOT 17 LOT CONTAINS 5.76ACRES AND EXTENDS TO CRAZY HORSE FLOWAGE. BUILDING SITE EL. =1,315'. FLOWAGE EL. = 1,260' APP.700'TO FLOWAGE �. �F y HOLDING TANK SPECIFICATIONS 2 Number of bedrooms Non-residential estimated flow(gpd) :Z,Ooo Minimum holding tank volume required (gal) Side A Side B Total 1411.0 754.0 —�Proposed tank capacity (gal) Skaw Precast Tank manufacturer 1200/750 Tank model number SJE Rhombus Alarm manufacturer 101-10H Alarm model number Tank Dimensions and Data Tank Anchor Calculations X for round tank 16100 Ibs Weight of tank and cover 47.0 Liquid depth below inlet invert(in) 1.50 Safety factor 8.0 Maximum depth of soil cover(ft) 23081 Ibs Weight of anchor required 61.0 Height (in) 1 33.6 in Soil cover req. for anchor or 154.0 Length (in) } SJ yd' Concrete counter weight 77.0 Width (in) � HOLDING TANK CROSS SECTION Electrical complies with NEC 300 and SPS 316 optional vent pipe vent pipe manhole cover with � finished location � locking device and grade junction warning label box —� — �4"min. 4"min. �-23 in. contluit � 18"min. thether - � /wei9nc Note: All tank joints, and joints - � IG between tank openings and buiid�ng sewer a arm on — p�ping are sealed watertight. All iniet blind plug pipe and vent materials comply to seal ouuec with SPS 384. Manholes with 90% Full 33.5 in locking device are typical for each manhole opening . 754.0 gal 1411.0 gal 3 in. bedding under tank. Tank is anchored as necessary to negate buoyancy. Project: Transaction Number: Page�of 4 PAGE40F4 Holding Tank Management Plan IMPORTANT: The owner of this holding tank(s)shall be responsible 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. Furthermore, all inspection and maintenance activities shall be performed by a registered POWTS Maintainer in accordance with SPS 383.52 (3),Wisc. Admin. Code. Estimated Daily Wastewater Flow= 2Q A gpd Insqection Checklist INSPECT EVERY 3 YEARS o type of use o age of system o nuisance factors (i.e. odors, user complaints, etc.) o mechanical malfunction (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 surface 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 inveA 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 government unit in accordance with SPS 383.55 Wis. Admin. Code. RepoR any component failure or malfunction to: Name of individual or company: BfOWII's Excavating Phone: 715 943 2390 �o�ai 9o�er��r,e�c ��t: Sawyer County Zoning Dept. Pno�e: 715 634 8288 �oca1 government unit address: 1061 O Malfl St #49 H8yw8fd, W) ZiP: 54843 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. Continqencv 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. WARNING OEATH MAY OCCUR/F TANK IS ENTERED O WITHOUT PROPER EQUIPMENT j SKAW 1200/750 � i n i O � 70.00 �J � I NOTE:SEE INNER WALL PHOTO ON THE"EXCLUSIVELYAT SKA W S"PAGE. � � i i i i i i h1QX, i�r' 04pQer�� : � ��5� �alb�s � 1 I I I I 1 �l'�" x i5H" ' ' � � 6r�� x �a.s' I I 3.00 � � � � i i 4.0o i i � �- L_____'_'______'__"'_'_______J �27.00� �27.00� 27.00� sa.00 14,00 �za.00 OUTLET END VIEW OF TANK 5.00 I 16.00 7.pp-� 2.00 200 � INLET �� / 9.00 � V 2.pp 78.� 4 INCM 41NCH PRESS � PRESS SEAL GASKET S�� INSTALLED GASKET WHENPOURED BAFFLE FILTER / 47.00 3� SECTION VIEW OF TANK AND COVER 3.00 Model Number. 72�0 � 7.�1� SKAW PRE-CAST PhOn2: (715) 967-2277 Approv6d for: SEPTIC/SEPTIC,SEPTIGPUMP,SEPTlC/SIPHON OR HOLDING Toll Free: 1-800-924-8625 eig n e im. u e �m. ��q, Depth Gal./In. Nom. Cap. z6255 105th Street, New Aubum Wisconsin 54757 Fax: (715) 967-2707 16,1001bs. 54" 50" 47" 16.05 754.35ga/. www.skawprecast.com HOLDING TANK SERVICING CONTRACT Contract Date: /� /�_ This contract is made between the Holding Tank Owner and the Pumper. Holding Tank Owner's Name: Pumper's Name: G�LAY� `�7�..1-�I4 n ,� �`{-W�� NCi � ��i `S1��5 Parcel Identification Number: �1 (12 Digit Legacy ID) � ,Z �-� 3 8 - O 4 - Z.=L Q� 1. The owner agrees to file a copy of this contract with the govemmental unit, Sawyer County, which has accepted and recorded with the Office of the Register of Deeds,the Maintenance Agreement for a Holding Tank required under the Sawyer County Private Sewage System Ordinance for the issuance of a Sanitary Permit for the installation of a holding tank(s). 2. The owner agrees to have the holding tank(s)serviced by the pumper and guarantees to permit[he pumper to have access and to enter upon the property for the purpose of servicing Ihe holding tank(s). The owner a�rees to maintain the all-weather access road or drive so that the pumper can service the holding tank(s)with the pumping equipment. The owner further agrees to pay the pumper for charges incurred in servicing the holding tank(s)as mutually agreed upon by the owner and pumper. 3. The pumper agrees to submit to the Govemmental Unit, Sawyer County,a report for the servicing ofthe holding tank(s)as required under SPS 383.55; Wisconsin Administrative Code and the Sawyer County Private Sewage System Ordinance. The pumper further agrees to include the following in the report: a. The name and address of the person responsible for servicing the holding tank; b. The name of the owner of the holdin�tank; c. The site address of the holding tank; d. The date the holding tank was serviced; e. The volumes in gallons of the contents pumped from the holding tank for each servicing; f, The disposal si[es to which the contents from the holding tank were delivered. 4. This agreement will remain in effect until the owner or pumper terminates this contract. ln the event of a change in this contract,the owner agrees to file a copy of any changes to this service contract or a copy of a new service contract with Sawyer County within ten(10) business days from the date of change to this service contract. Owner's Name:(Print) Ow�e�'S SigTlBtulO:(Only one ownersignature rcqoired) � ,�.� 3�.,�� .�2�`-'-"�-_ Pumper's Name:(Print) Pumper's Sign ture: lj`1�T,�� G�4�� Pumper's Registration Number: 2 7 L�i Rev.03R6/13 Real Estate Sawyer Counry Property Listing Property Status: Current Today's Date: 9/11/2023 Created On: 2/6/2007 7:55:34 AM �� Description Updated: 3/29/2022 �r� Ownership Updated: 8!9/2022 _-------. _ _____ _. -- ----- . �_,_. � .�__ ---- ------- ----____ Tax ID: 20451 MICHAEL A & KAE M MILTON WI PIN: 57-020-2-38-06-04-2 04-000- SHISLER 000060 Legacy PIN: 020638042406 Billing Address: Mailing A dress: Map ID: .8.6 MICHAEL A & KAE M MICHAEL A & KAE Municipality: (020) TOWN OF OJIBWA SHISLER M SHISLER STR: SO4 T38N R06W �°�"T��U�-� 7��-��V-£�F�-�R �� R�TL ��1� Description: PRT SENW, NESW, NWSW, & ��'�� 3 3 LAll1`S/►�ILTH,�1 SWNW LOT 1'7 CSM 27/169 �'4�4� #7073 ir:; Site Address * indicates Private Road Recorded Acres: 5.760 8777W WHITETAIL CIR * A OJIBWA 54862 Lottery Claims: 0 First Dollar: No �� property Assessment Updated: 8/20/2013 Waterbody: Crazy Horse Flowage --------_�_.�._.__,__________.___.. ____� _____ 2023 Assessment Detail Zoning: (RR2) ResidentiaURecreational Code Acres Land Imp. Two G1-RESIDENTIAL 1.000 29,600 0 ESN: �2 G6-PRODUCTNE FOREST 4.760 5,200 0 ;�;: Ta�c Districts Updated: 2/6/2007 --___-----_-----------__.___________�__��-- ---- 1 State of Wisconsin 2-year Comparison 2022 2023 Change 57 Sawyer County Land: 34,800 34,800 0.0% 020 Town of Ojibwa Improved: 0 0 0.0% 576615 Winter School District Total• 34,800 34,800 0.0°/o 001700 Technical College • l,�� Recorded Documents Updated: 11/26/2007 ;,�.:; property History _ .____. ----______.___ _._.____ �___V___ _ — - ------_ ._____u_._ ._.__.._�____._.,.,_.___�.._�..�_____e._. E�r WARRANTY DEED N/A Date ��8 Recorded: 7/29/2022 ls.; WARRANTY DEED Date 350788 Recorded: 12/11/2007 1.�� AMENDED COVENANTS Date 349639 Recorded: 10/15/2007 i�� AMENDED COVENANTS Date 342058 Recorded: 10/4/2006 't�� AMENDED COVENANTS Date 341110 Recorded: 8/24/2006 �� COVENANTS Date 332945 Recorded: 8/29/2005 ir:� CERTIFIED SURVEY MAP m s� ��c,�; �� . 7�- �.i� :n ��S�t'w- �� 7� z��.s � �� , ti. ? ._-�Sfi: yq,�� ;k�•�} ..: � _ y. }, 1P ,e 7f�t,� �F��, .�a �,�q, ^�.� �� k�(��.' ,7 Q{.Ait � � L .y`�'k. � ��j �., C� 1. ',�. ..��4 S / yi � ?��f i-, $ g � � � y k +o t^� .. -}�}'4. .v"��1Q l� , ..�"s �" 4 J �,"C�� r��,�� t��:',� , rh. l s ".�b' . ri�., !. . o «f..� ', �".. .ry9�,y,� ,;.° `�k '� C!'[ - C` : ^+�f �,`4 V�f '��e��. �'^z:.. W C . c5a T �'�� .4 `�'t�� r�� i�I f��1S: S ' �t 5 n �� li� } �� '�, gR 4 r• � . S C y T �. !, - �R. ' —�1 '�� .L c d+ � '�2 A'?7 _ '� � ' 4 � q� ! `W '�.°�{,`• � K �h\� --�y ..y -"b � �• � T' �' _ �„ ' S l'�- �,, ��,,� -�6T�` ��''y' . 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Li�i.. ��,F":`.C3p�:'.��i � ti � - �a�i ;�Tt� - - _ i I �II IIII� IIIIIIIII I illlll I - USE BLACK INK ONLY - DGCT� :80'4��;2 POWTS MAINTENANCE AGREEMENT Tx :4047i14 For Holdin Tanks 446618 9 PAULA CHISSER Owner's Name(s) as shown on deed: REGISTER OF DEEDS SAWYER COUNTY, WI 1 1�nC 09j29/2fl23 01:17 PM N� i �ha�-1 � � �� , Sl� � c1�G _ �� ' �'\ , J� ' �J�� RECaRDING FEE 3Q.00 Parcel Identmcation Number: (12DigitLegacylD) �/ � � ' � � � ' � �+ ' �� PAGES: 2 Legal Description of Property: - SEE ATTACHED SHEET - We acknowiedge that appiication is being made for the installation of a holding tank(s) on the property described on the attached sheet. Retum To: Sawyer County Zoning and Conservation Administration 10610 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 govemmental 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 govemmental 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 govemmental 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 municipal 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. -Only one owner signature required - ACKNOWLEDGMENT Own ' � ature: State of: � �/U `��^ � �"� County of: �Gt,�-�l ye �" O ner's Name Print): Subs ribed and sworn ts� before me on this /`Y/ lG�, �, J`�� ;5r�y' N•» .,,�_day of �ZP �' , , 20 c�S Date: �y�.OZ �I�V_�q�Owner's Name): ; nc �c.�. ' � �/cT y�/�/zaa�.3 - P..�� '�ot�jr Public Signature: ` ' Drafted by: :� t1� RJ'Pt�blic�Notary Name (Print): �� /o ��c� ' ' Z ��- K-� Z�� ' � • - - My co�nmission expires on: " I a - s ' U8�-�G •' �.: ss Nj,•. �, �'9 .+ � �'•. ....••'� Personal information you provide may be used for secondary pur��F � , § 15.04 (I) (m)] Rev. 03/26/13 NMNINNN Parcel 1: Lot 17 of Certified Survey Map No.7073,recorded in Volume 27 Certified Survey Maps,Pages 169-170 as Document No.332510,being part of the Southeast Quarter of the Northwest Quarter,the Southwest Quarter of the Northwest Quarter,the Northeast Quarter of the Southwest Quarter and the Northwest Quarter of the Southwest Quarter of Section 4,Township 38 North,Range 6 West,Town of Ojibwa,Sawyer County,Wisconsin. Together with a non-exdusive easement for ingress and egress as shown on Certified Survey Map referred to herein. "T''�`;� PRIVATE ONSITE WASTE TREATMENT county ��o$ SYSTEMS ,-:�,`� P S S awyer , ( POWTS) k ' '' INSPECTION REPORT Sanitary Permit No: Safety and Buddings Division (ATTACH TO PERMIT) GENERAL INFORMATION � � — 2�� Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(1)(m)J Permit Holder's Name: ❑City ❑ Village [�Town of: State Plan Transaction ID#: ►M��,�.� a- c,c�. 5�;��- n;;�,a►o � Insp BM Elev: BM Description: Parcel Tax No: �G�.t7( �`o�a T C-bv`C . `S\`'b �\\�b. ��-b3 LS'� l -2��0 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV Septic Benchmark �p,�� Dosing Aeration B�dg. Sewer g 8,�� Holtling sk�-ln� �� St/Ht Inlet �6, ( ' TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L WELL BLDG VENT TO ROAD Dt Intet AIR WTAKE Septic NA Dt Bottom Dosing NA Installation Contour Aeration NA Header/Man. Holding .�-�� '7 �-'� �-�5- Dist. Pipe PUMP I SIPHON 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 �N L #of Cells Type of System Distribution Media Manufacturer: SETBACK OHWM of Nav ° Conv ❑ Aggregate INFORMATION P/L Bldg Well Waters � IGP o Chamber Model Number: ❑ AG o EZFIow CELL TO ❑ Mound o Other - -_. _- — _---- _-- _ __-- - ---___—_ - ---_._— ---- DISTRIBUTION SYSTEM X Pressure Systems Only g . — -- — _ _ Header/Manifold Distribution Pipe(s) II X Hole Size X o eH I Observation Pipes Len th Dia Length Dia Spac , _ Spacing ❑Yes ❑ No � _ __ _ SOIL COVER -- - ------- . — ___ - Depth Over Depth Over T Depth of Seeded I Sodded Mulched _Cell Center �Cell Edges Topsoil _ _ � ❑Yes ❑ No � ❑Yes ❑ No , COMMENTS: (Include code discrepancies, persons present, etc.) /`��s}�/(� 1► �I Y ��3 � N ,�-� -- �r - __ _ _ � Plan revision required?❑Yes ❑ No I03 ;��a� � �� I �-- -- --_ _ � ��S�l-� � 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 � � ��5� �`— (�� , C ko�5.e, ��4 c�✓a5 Q. / ' . ' ! : . _j_ : �_ : ,_ . _ : ; ; . ___. _ .. _ _ _ , ___ . _ <. ,- _ . ._ ____ _ , . , .. . . - � I � �. ; .__ � : , : . . �. r_ � . � , . .�¢K'� �vv �` ' 3 �°� F � 8` � P`�� g�n� `' 2� � � �� / y5 �C �\ � U�v� � � / � �'� 1�';�'. �� fl �� i�' " �- S�ttFt�-- 1