HomeMy WebLinkAbout010-841-35-5306-SAN-2023-261 ` '"� Industry Services Division County �
� , �_ 4822 Madison Yards Way SBWyeY �
- _ S' - Madison,WI �370� Sanitary Permit Number(to be tilled in by Co �
s P.O.Box 7302 �
Madison,WI�3707 Cos� �5 � W
State Transaction Number �
Sanitary Permit Application ____ F�
In accordance with SPS 383.21(2),Wis.Adm.Code,submission ofthis fortn to the appropriate governmental unit E
is required prior to obtaining a sanitary permit.Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing add —
the Department ot Safety and Professional Services.Personal infonnation you provide ma��be used for secondary 2614W COUfIt�/ RC�. B. �"�a�/WafC�, W�
purposes in accordance with the Privacy Law.s. l�.Od(I)(m),Stats.
I..4pplication Information-Please Print All Information
Property Owner�s Name Parcel#
Maureen Bitney 010841355306
Proper[y Owner�s Mailing Address Property Loca[ion
4921 Beacon Hill Rd � ��t 3
City,State Zip Code Phone Number
Minnetonka, MN 55345 612-750-5444 ��`� � Se�t�on 35
I1.Type of Building(check all that apply) Loc# T 41 N R �$ F,or�
�I or2 Family D��elline-NumberofBedrooms 3
'-� Subdivision Name
Block#
❑Public/Commercial-Describe Use
��
Ciry of
�State Owned-Describe Use CSM Number Village of
��
QTo��„of Hayward _
IIL Type of PO�i'TS Permit: (Check either"New"or"ReplacemenP'and other applicable on line A. Check one box on line B.Complete line C i
a licable.)
`�� �New System �Replacement System Other Moditication to Existing System(explain) �Additional Pretreaunent Unit(explain)
k Only
B' �Holding Tank �[n-Ground �At-Grade �Mound �[ndividual Site Design Other Type(explain)
(conventional)
�• ❑Renewal Before �Revision ❑Chanee of Plumber �Transfer to New O��ner��ist Previous Permit Number and Date Issued
Expiration San 84-087 �jls2918
IV.Dispersal/Treatment Area and Tank Information: �
Design Flow(gpd) Design Soil Application Rate(gpd/st) Dispersal Area Required(st) Dispersal Area P System Elevation
450 �,�xisting p _ �xi�stirrg- (� .3 93.5 Ex.
Capacity in Total #of Manufa urer
Tank InYonnation
Gallons Gallons Units � � o ? o
U
1��e�e Tanks F�i,c�ing Tank,e .rs o � ,—� �. n :r
` � =� L c�.s c3
a U v� � v� r_ V �..
Septic or Holding Tank �000 �00� 1 Wieser � �
Dosing Chambzr � � �
V.Responsibility Statement- [,the undersigned,assume responsibili for install�tion of the POWTS shown on the�ttached plans.
Plumber�s Name(Print) Plumber's Signature MP/MPRS Number Business Phone Niunber
Jason Kuettel " �; ��y 675751 715-798-3355
Plumber's Address(Street,Ciry,State,Zip Code) f .
PO Box 66 Cable, WI 54821
�'1.County/Department l'se Only
1 Pennit Fee Date Issued Issuing AQent Sienature
�Ap ❑ Disapproved $ / ,
�O��ner Given Reason for Denial �Q�,� �� f�!`�� ���t'�'�����Z �
Conditions of Approval/Reasons for Disapproval � ���� `.` r'"��� s ,1� •,`
i i i
� , � o � � ���/��t., ���r� �:,�' �� �
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3�10 ��1WY�� 4.�<!n;-`"a
�C�NIN(��ADM��l���i��;:;i�J:
Attach to complete plans for the sr�stem and submit to the County only on paper not less Ihan 8 I/2 x 11 inches in size i � 0.�'�r
3 J
SE3D-6398(R.02/22) �C R�=�UN��r��1'�fr�
I�j�J�Or P£��1'i
�r'l�
PAGE 1 OF 4
In-Ground Gravity Plan
Index & Cover Sheet
Component Manual Design References:
In-Ground Soil Absorption for POWTS Version 2.1 (May 2022-2027)
Pg 1 of 4 Index & Cover Sheet
Pg 2 of 4 Plot Plan
Pg 3 of 4 Dispersal Area Cross-Section & Plan View
Pg 4 of 4 Management Plan
Attachments: Enclosures:
POWTS Application for Review
Soil Evaluation Report & Site Map
Project Name / Description
Bitney Tank Replacement
Owner Name(s): Maureen Bitney Phone: 612 _750 _5444
Owner Address: 4921 Beacon Hill Rd. Minnetonka, MN Z;p; 55345
Project Address: 12614W County Road B. Hayward, WI
Govt. Lot: 1/4 of 1/4, Section 35 , T 41 N-R 08 E❑or W �
Township: Hayward County: Sawyer
Project Parcel ID #: 010841355306
Designer Information
Designer Name: Jason Kuettel Phone: 715 _798 _3355
Designer Address: PO Box 66 Cable, WI Zip: 54821
E-mail: tim@andryras.com
License Number: 675751
Remarks:
Signature: Date: � ti z3
Original si a re required on each submitted copy.
L
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APorO'/C� P•1FG. C}l{'-�'1C�
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Oi`tT0 SOLIO m�d�l n �j�,���z,
SOIL
3 �� ,:�..r�:u'yj�� E��r�sr�� ui��p ��Ntt
SPEL.IFICtitIc��l�
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Tf;J`,(� t-i:�11.1:."tC�I..�Y�., . V.li�S C.'�- �..4`'NC:'k.'T�
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t�iOTES :
PAGE40F4
In-ground Gravity Management Plan
IMPORTANT:
The owner of this in-ground gravity system 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 system 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.
Maximum Dispersal Area Oqeratinq Limits:
Design Flow= 450 yPd; BODS<_220 mgL-'; TSS<_150 mgL"'; FOG<_30 mgL"'
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 malfunction(i.e.,pumps,valves,switches,floats,etc.)
o material fatigue(i.e.,leaks,breaks,corrosion,etc.)
o solids volume in anaerobic treatment tank(s)and any distribution appurtenance(s)(i.e.,distribution/drop boxes)
o neglect or improper use(i.e.,exceeding design capacities,prohibited activities,etc.)
o extent of ponding in distribution cell prior to dosing
o dosing irregularities-if applicable(i.e.,pump re-cycling,float switch settings,etc.)
o electrical components-if applicable(i.e.,wiring,connections,switches,controls,timers,alarms,etc.)
o distribution lateral or lateral orifice plugging (measure lateral distal pressure-compare to design specification)
o surface discharge of effluent or sewage back-up into structure served
Maintenance Checklist MAINTAIN EVERY 3 YEARS(or when necessary)
o Septic and dose tank(s)shall be pumped by a ceRified septage servicing operator licensed under s.281.48 Wis.
Stats.when the volume of solids in the tank(s)exceeds one-third(1/3)the liquid volume of the tank(s)or
as required by local ordinance. Disposal of contents shall be pursuant to NR 113,Wisc.Admin.Code.
o Effluent filter(s)shall be inspected every 3 years and shall be cleaned when necessary to remove any
accumulated solids according to manufacturer's specifications. A servicing period will always be greater than 12
months.
System maintenance reports shall be submitted to the proper local government unit in accordance with
SPS 383.55 Wisc.Admin.Code. Report any component failure or maltunction to:
Name of individual or company: Alldry R8SfT1USS@Il 8c SOIIS Phone: 715-798-3355
Local government unit: S2Wyef CO.Z011lllg Phone: �15-634-8288
�oca�government unit address: 10610 Mairl St. #49 Hayward, WI Z�p 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.
Contingencv Plan
In the event that any failed treatment component of this POWTS cannot be repaired,it shall be replaced pursuant to
a plan submitted to the appropriate agency for review and approval. A failed in-ground dispersal component may be
abandoned and replaced by a code-complying dispersal component in a pre-determined area of suitable soils.
Svstem Abandonment
If use of this POWTS is discontinued,it shall be abandoned in accordance with SPS 383.33,Wisc.Admin.Code.
�°"�'^ APPLICATION FOR SANITARY PERMIT
� DILHR Sawyer �'
�OUN7V
��mme�r� (PLB 67) UNIFORM SANITARY PERMIT� -.�
r
�meuBrw.uaew¢�tumnntm�menn CST- 84-0 89 S� '�7 R _A
G
—Attach complete plans in accord with s. H 63.05,Wis.Adm. Code for the system,on paper not less than BY:x 11 inches in size. ' J
—See reverse side for instructions for completing[his application. PLEASE PRINT bI D— — 5
P 0 E Y OWNER � M NG DDRESS
1
( [.VR /.t/ .SY�
PROPERTY LOCATION -@f{i�--
V S'�$,".`v� �
[�J 1/4� 7/4 S Ty , N, R 8' r) W row oF: a
LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAR T RO LAKE OR LANDMARK STATE PLAN I.D.NUMBER
Ct/
TY�P,E.�/OFg�ILDING OR USE SERVED
JS 1 or 2 Family Number of Bedrooms: � [, Public (Specify�:
THIS PERMIT IS FOR A:
❑ New ystem ❑ Tank Replacement ❑ Repair
eplacement Soil Absorption System ❑ Revision ❑ Privy
U Alternata System Cl Reconnection ❑ Petition for Modification
IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK.
�!�'epaye Bed ❑ Seepage Trench U Seepage Pit ❑ Holdiny Tank
❑ System•In•Fill ❑ In•Ground Prassure ❑ Vault Privy ❑ Pit Privy
❑ Existing, For Which A Previous Permit Is On File,Permit # issued
❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions.
Tocel oi Pretab. Site Steel Fiberglau Plascic
G811o�5 Tanks Concreta ConStrucied
Septic Tank Capacity
litt Pump Tenk/SiPhon Chamber E �j � (��
Holding Tank capecity
Manufecmrer:
IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound U In-Ground Pressure
Totel #o� Prafab. S�te Steel Fiberglass Plastic
Gellons Tenks Concrete Construeted
Septia Tenk CepeNty
LIt[PumpJS�phon Chamber
Manufac W rer:
PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY:
(Minutes per Inchl: REOUIRED ISquara Featl: PROPOSED (Square Feetl:
e � 6 (,S—^ (o [ S�— Private ❑ Joint ❑ Public
I,the undersigned,hereby auuma responsibility for in ati of the private ewage system shown on the attached plans.
Na of Plumber(Print): Si tur • MP!^"Pa�'"'^'^: Phone Num6er:
cv/� c� a� lDT v�i`� 63 f�-Yt
Plu 's A ress: � Neme ol Designer: �
e_ � � P c�',oz.ai
UNTY/DEPARTMENT USE ONLY
Sig r o(Issuirtg Agent: Fee: Dete: ❑ DiSapProved
❑Owner Given Initial
Approved Advarsa Determination
eesan for Disa ovel:
Alternate mursels)of Action Aveilehle:
DILHRSBO6�98 IR.6/e]) DISTRIBUTION: Originol to COunty, One Copy To; Bureau of PlumbinB.Owner,Plumber
�
s INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398
To be complete and accurate the permit applica[ion must include:
� 1. Property owner's name and complete legal deuription, please circle the appropriate municipal government unit, (whether this is in
a city,village or townl; �
2. Indicate specifically what type of use is served, if public is checked�indicate type of use (i.e. 10 unit apartment,30 seat restaurent,
etc.l;
3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks.
4. Indicate the design percolation reta listed on the 115 soil test report,the number of square feet required by code and the number of
square feet to be i�stalled;
�
5. Complete the section on water supply;
6. PRINT the name of the master plumber or master plumber restricted who will install the system,circle the appropriate license classi-
fication, place your license number in the space provided and sign the permit in the signature block;
7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the
permit;
8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67•T) to be submitted to the county prior to installation.
Failure to comply will void the sanitary permit.
9. This permit may be renewed, and at Ihe time of renewal any�ew criteria in the Wis.Adm. Code will be applicable.
10. A new permit will be needed if there is a change in,estimated wastewater flow, (number of bedrooms,etc.), location of the system,
- depth of the system, rype of system.
11. All revisions to this permit must be approved by ihe permit issuing authority.
12. A complete plan including a plot plan,drawn to scale or with complete dimensions.
13. Horizantal and vertical elevation reference points that are permanent and clearly shown.
14. Piping detail including pipe size,separating distances,distances between beds if appropriate,tank locations,effluent line from tank�s)
ro system, building sewer and vent observation pipe(s). ,
15. The permit issuing agent may require a cross section drawing of the effluent disposal system.
TO THE OWNER: Thi� is valid (or two yoars. Changos in your buildlnp plans or locatloro mey roquiro you to obtain e new permit.Private aewe8e rystems
murt 6e properly maintained.Have a licensed Oumpar elean your teplie tank whenever nacessary uwally every 2 to 3 yeus. If you hava questions eoncerning
your system,eontact your Iocai code adminictrator or the Bureau of Plumbing,DILHR,State of Wiuonsin.
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a��r�aTn�Erv�- a� i�vous�r�v, INSPECTI�N REP�RT FOR sAF��v & au��.o��vc.
LRBOR & NU�iIAN REI,ATf(JNS p� ��JqTE SEWAGE SYSTEMS aiv►sion
P.O. Bt?X 79G�
AAAfll501V, Wl 53707
BUREAU {5F PLUMBINC
�CO�IVENTIQ(VRL :�JALTERNATIVE s,s,�e�.�a �� r:,,.ri��.
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SEPTIG TANKIHOLDING TANK:
±Nz:�,iat.ri,+�tr, , s�i.: � cap.:u�Tr .. .r ��.er � €ir��`" aar�.��u;tt7 � � ,vE �
• ' � s Fift V'l�rib( �GLASf�,I t t ni � i
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a a�h^. U B O �trrc �nEn n�tF'
FEET FR011A
C�v�s [�irvo !�IvEs �ln���. N�aa�sr � ,� _ ._._ a_
OOSIN�i CNAMBER: ��������� � ������y� �
F�n�,t�� qt7�ttet4�� HEDDtrec, � r5+_�i�� -. r� ,�[rs � ��;. � � �i,e�� ;��•.i +� .r.:�:��ar�ta.i=fiF; ..'�'— fiAHLt..G �a9E. ttt'r:.iN; rtSVEa
������ . .. t�Gi] IJE`.� � �e1Vi[5E )
f.._ , YES ,�;,N�7 � YES _ ;Nt? � Y�5 ;Nt�
GA�L{�NS PgR GYCE.E. .._� .�_. , �ea .a��rc���rnv�u�tie��•�t:a� NUMBER OF �,s>'� . _. �_��.� �,_ � r r� r€�ts.�
{OIFFEREt4CE BET4'�EEN PEET FROtv1 . '�� ``e ;
PUtbtP {)N AND OFF� � :YES _;M1iO NEARE�T
SOfI A�SORPTiON SYSTEM. Check the sail �nta�sturc at th�da�th oz taiotivin�p — FORCE � " . - �" ,:,''�• -:� •, �'r` . , _.'.'"�•�.<��
�r �,�cav,�r�rar� fl( so�i car� bc! �otled �nte� � wire, con�trucr�czn shall ceraxe �i�t�i MAIN
th« snii is dry �r�ough tr� continue.)
CONVENTiONAL SYSTEM: ��������
. . n..� � t :ll )Iti`{2 VkPk F.+4:.1": v1.ii i• ¢ I !i R( •. IQl3IU
IUL� . . Ue r . . •�
� BEDlTR�NCH I � i���r�� .,��� � �;rrrr,:.i �IT � es�rz��
DIMENSiJfVS ( � �-�. � ---- � S-�r0.W
!.�li 1( I.!�1 7!��— I ll L Jf:P �f fJl-.•f 4 41V��;r ••••• . — ..4..�•�� � • �
... . ����
{ll fl f fFf CJISiR PIfTE MA�kldlAl. at} UIi�H ���g�� �F � Ft ]I gt"i!-Y '�yE:.L t#ult )I"� . L� J � If1 FHESN
EJi i .:. r�f�t , ,�t.,.E�(� 'L,� Fi i r i r 4 ci f k'gtl N�.h:. , � � L aE � ► �j nE{i i�sSzEt
�� _�p �..���a_ �`� �._��.�C.4�,�,� �....v..� �EAR�s°�'—,.� ...__.�S _�l�_ > 7O 7 7 0 �
�wourua sysr�nn:
Mounct z�tt� p�ov�ed pe�penclicuiar to sic�pe Chec€€ the texture of thr� fill material ipr PRQVII�E A DIAGRAM O�SYSTEM
mo��nci sYstern� to m�ke certain thai it ON REVERSE SIDE. SHOW I:L�VA-
�nct furro+�vs thro�.vn upslope: ��� � � � ��
r {-7
� m�ets the cr�t�ria for m�ci�um sancl. � TIONS MEASURED.
,�+YES '._�NO
SOfI,. COV6R ��'.,�� ��._ .i�i+.e . . �.<:�rat ��; �s-
C aYEs C �)n�r� v�s i_�nra
a.,._ _�. _.� �.� _�
L1iVPt+ f)Vttri�lt `J{.��:p)�l} I7fP1��€!V( �it�i€^J4;y4 �IPt#�. �. k1Plit� y� (isCl(liL � ��I"UttS '��ilsl.J *��I [ HI ;)
CItJTtN EUr>iS
�_iYES C_,�Nt� �._IYES �NO �-��'�$ r�N�
PRE5SURtZEQ DISTRIBUTION SYSTEM:
� ti,.� �t�a �a�>,.:e. s�E�-., ��:�c.•r: at�..� � Fi4;. :�E"r � x< <.%���t���
� :i' S7�i LE`ais i)t iy£t �� 'c l5i Av�!:(a � �7 �' e� n
BE�tTRENCH � ir�cr.e���� �
dIMENSiONS , �
+t�.�'s�er H.,�F .:'*7� a..i� " 7ze.S2 YI2`� '.!-tM kCse.e;�RAt�n� , stts. ..jTtx a�..'— .� gt.7�� . s r£`,�•.f� s:+tit s 'fht2� . .
�
r:. f.teY ,.�A t..f*: 3, ! � ';_A
ELEVATNJN ANO
OISTRIBlJ710N
INFORMATION � "��-eaits ��r� [ ,;aa:,is,:, ,��it��t.� .;u��crcr r�;v=r� rrr.r�Ria� 4��tic�� .�ct �c���at , t�,��� r.. ��vr,�ave�
>'Ld`.:S
,,_ (�vEs C�In�� _ ..�� .___. �v�s �:JNa
�lNMqfaENtR1AHr.tN$ pp;�EyVATIt)`� Y:kL4S PitG��NT`F VYCL� I3LlI�.plryt5
COMMENTS: � ,_� �j��ARESO�
. LINE � ._.._,_�., .
L� Y�S CJNO � YES L�NO
Skcteh System on Retain in courtCy filt for auclit.
Reverse 5�de.
�1{;`J� U. E [iYtl , .
ni�HH ssa s�10 ��, n��a�� , t ��\�.�� �5�. ��t� t _ f�R�1_
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:1.3 � 3.7
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3.9
:2.2
:2.3 3.4
� :2.1 3.1 .3.4
� I :3.12
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\ I :3.3
�l :2.4 :3.5
i 2 3 4 s G
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9.2 .ra.a 3.�0
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14.1
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4 3 �' 14.5 13.�
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I14.2 13.2
I
15 4 4.q
'4.2
'4.1
I5.1 IS 3 �
4.5
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15.2 :4.9 ///�o
IS .b 4.io // �,
- 411 T �/�.�v � :9.i2
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: I INCN= 4oa FEET
: BY: fOR ASSESSMENT USE ONLY NOT
DATE : INTENDED TO SHOW GONCLUSIVE
`! (�) INDIGATES GOVT. LOT �VIflFrtlrc nr n„�.�,.,,,.. ,,., _ _
: �
"�`"��,,, pRIVATE ONSITE WASTE TREATMENT co��ty
= � oS ,� SYSTEMS SaW er
� P �
-:,,� s ( POWTS)
H �_ .�
�"�'� INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION a 3 ��-(o�
Personal infonnation you provide may be used for secondary purposes[Privacy L.aw,s. I�.04(I)(m)]
Permit Holder's Name: ❑City ❑ Village �,Town of: State Plan Transaction tD#:
��\a��y V��h°�r �a.�w�� ^
Insp BM Elev: BM Description: Parcel Tax No:
Lab-° � `��,� 6� �-�� �i°-��{� --3s-5�30�
TANK INFORMATION ELEVATION DATA f
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic „„�p�.�r �p Benchmark oo,p �
Dosing
Aeration Bldg. Sewer
Holding St/Ht Inlet 6,�( '
TANK SETBACK INFORMATION St/Ht Outlet �g,��
TANK TO P/L WELL BLDG VENTTO ROAD Dt Inlet
AIR INTAKE
Septic �.�p �' ' }��.� NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header I Man.
Holding Dist, Pipe
PUMP 1 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 W � #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv � Aggregate
INFORMATION P/L Bldg Well Waters ❑ AG ° Chamber Model Number:
❑ EZFIow
CELL TO ❑ 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 �
I
_ -- __
SOIL COVER
- -- --— — ---__-- -
De th Over De th Over De th of Seeded/Sodded Mulched
P P p
Cell Center Cell Edges ; Topsoil ❑Yes ❑ No � ❑Yes ❑ N�
COMMENTS: (Include code discrepancies, persons present, etc.)
��}�►(� co12Y�23
'� S� ,�,��, ���
-_ _ --- - - �
Plan revision required?❑Yes ❑ No � 03'�� ;� j � �G2�`�`- I � r�
� - 1"' - -- - 6�
Use other side for additional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NIJMBFR: �3^�6 I
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