HomeMy WebLinkAbout008-937-17-5423-SAN-2023-318 .'-'-••r;j;�. Indushy Se�vices Division ��� � }T
'" 4822 Madison Yards Wa}�
':i/��_' - Madison,W[53'705 Sariitary P mme Numher(to be filled in by( �
, f : P.O.Box 7302
\o.; _ ;'c,'% Madisoq W[5302 (;i� � �O� 9J
_ W
Sanitary Permit Application �eT!a�!aactionNumber w
In accordance with SPS 3R3.21(2),Wis.Adm.Code,subnission oft6is fmm to lhe appropriate govcmmental unit
is rzquired pnor io obtaining n sanitary(x.mmiL Note:Application forms for slate-owned POWTS are submittad to Pr ject Address(if di$zrent than mailing a� �
tt�e Department of Safety and Rof sional Sm-ices.Personal�rmation you provide may be used for seewndary
� ccordance with the Priva Law,s.15.04 I m Stats. ��/
L A 5etiwtion Information-PleasePrintAlllnfurmatloe j� �
Propertv Owner's Name Narcel d 9 �
IQs aa G o0893�•iir za
Property Ownzr's Alailing Addrss Pro�pe,r,t��Locatirni
—7 d � c�,lao� �-/U c�fi'�A��
CiTy,S[a[e Zip Cade Phone Number �
W/ rn (�/ SY� �y �- ac ^ eE s�;�, I l
II.Type of Building(c6eck ali that apply) 7 �Ot� I 12 T � N R 0 F,o
�or 2 Family Dwelling-Number of Bedrooms J l v / Subdivision Name
❑PublidCommercial-Describe Use Dlock d ^�
� ❑City of
❑State OwnrA-Dzuribe Use
CSM Nurober ,p� ❑Village uf _
z[1L`- ���.2 M �o.m of��,�/' _
r.�
IIL Type of POWTS Permih(Checic either"New"or"Replacemeet"aed other applicable on Goe A. C6eck one boz on line B.Complete line C if
s licable.
`4� ❑New Syst�n �lacemeat Sys4m �Ckhea Modification to I�;risting Systern(explain) ❑Addi[ional PrzVea[mevt Unit(eaplain)
B' Holding Tazk ❑In-Grow�d ❑Ai-Cxede ❑Mound ❑Individual Site Design ype(ezp )
❑Other T lain
(couvenuonal)
C� ❑Renewal Before ❑Revision ❑Change of Plumber ❑'frensfer to Yew
ist Previous Permit Number arid Date Issued
Eapirntion Owner (�(y�� �
IV.Dis ersal/Treatment Area and Tank Information:
Design FI w(gpd) Desip{�Soil ication Rete(gpols� Dispersal Area Re uired(s� Dispersal Area Rnposed(s� System Elevation
30o st/� ,/�// /!/J.�' — /d:.t �.c�+
Capacity in � Total H of Ma�mfacturer o,a - � .a
TanY.lnfortnation Gallons Gailons Units � U•°'. . U �
New Tanks Ews�ng Tanka h` � g P.
�Y y y
� w
e
0
Septic m Holding Tnn.l-
1_
Dosing Chember
V.Reaponsibility Stateroent-I,the m�de�pred, an���dy ot the POWTS.ho on the ettrchea p�mu
Piu er's Name(Print) Plum s gnalure b PRS Number Business Plwne Number
!.n:l � �'� �� 7/�790—6 �'
P(umber's Addres(Street,Cay.Statz.Zip Co
21170 s� � w G.L
VL Co n /De ertment Use Onl
� o ❑Disappmved Pertnit Fze Dale Issued. Issuing Agent Signawre
❑Ownee Givrn Reason for Iknial $ (W� i 1� :d�,.1 `�{t�c-�f.t����-�-
Conditions of ApprovaUReasons for Disapproval ��
�y,� �� � �= ,r��������/��nD
r�`I�1�Y u..^i -�., �� ��.]--�'_._.,-....._._. ^
3 o as� �� •� NflV 0 9 2623�
/��.S.� �3_ ��\ � , z#�___._...__.
\ __._ _
�I` t $qWYERCOJNTY
_.,___. �p'K1tM1G ADMlNISTRATIOIY
Attaeh to comple[e plam for Ihe synlem and subMt to the County only on pnper nol leu�han 8 1R x l l lncha In�Ize —�.7(�
J� 1
NC RGFUNDSl�TER
ss�39s(R o2n2) I�Sl1E UF P�RArtlT
Sawyer County Zoning & Conservation Administration
10610 Main Street, Suite 49
���R c� 1� Hayward, Wisconsin 54843
��'1/ -��Ci �� (715)634-8288
�� ��,Z�I� FAX (715)638-3277
����- _ _ �, ,� / www.sawycrcount ov.��rg
� o� �� � I o � E-mail: sanitarian(a-sa�crcount *Y«,�v.ot�
I � '��' � � � Toll Free Courthouse/General Information 1-877-699-4110
, .y �..ij_,-Y .`��
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Holding Tank Approval Checklist
I. Sanitary Cover Sheet: Date Stamp �l / �`� / 23
Parcel ID# v v �_ � 3 '] _ ('7 _ S �( � 3
II. Plot Plan:
�Property Lines � Benchmark BM ♦
�Site Address �p North Arrow
� Structure p� 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 with Original Signature
Management Plan/Contingency Plan
Servicing Contract
olding Tank Agreement Form ($30 to ROD) I Z (d��a3
IV. Holding Tank Specifications:
� Tank Cross-Section: Manufacturer: e Gallons: 3��a
� Tank Anchor Calculations [SPS 383.43 (8) (g)]
� Locking device, chains/locks
� Alarin, electrical per SPS 383.43 (8) (e)
� 3" Bedding Material < 1/2 ``
V. POWTS Component Manual Reference:
�Holding Tank Version 2.1 (May 2022-2027)
Owner: �aq S � Plumber: �o�,eS�
Application Review Date: �1 � 9� (�a 3
POWTS Reviewer: �.-.- �
Namc
6`t '� ( � Rev. 4/27/2023
Credcntial #
PAGE 1 OF 4
Holding Tank Plan
Index & Cover Sheet
Component Manual Design References:
Holding Tank Version 2.1 (May 2022-2027)
Pg 1 of 4 Index&Cover Sheet
Pg 2 of 4 Plot Plan
Pg 3 of 4 Holding Tank Specifications
Pg 4 of 4 Management Plan
Attachments: � Enclosures:
POWTS Application for Review
Soil Evaluation Report&Site Map(if applicable)
Holdin Tank Pum in Contract if a licable)
Holdin Tank A reement if a licable
Project Name!Description
( �7��1�s /7Q��iS'/
OwnerName(s): ���Gr�rS /�ir�Gs � Phone: - -
�cn���:, �v
OwnerAddress: 7�.�a rllN;r,l�,.�lark L��! R��n.i,�s Zip: s�v,'�
ProjectAddress: /6 y35 O�,'�l� L<<ti.�� �;o�� a����-�� c�'-'
Govt.Lot:� 1/4 of 1/4,Section�,T 3> N-R�E❑or W�
Township: ��q,u;�<�rk County: Spui.i e
Project Parcel ID#: OU�d 93 7/7 S'/..?3
Designer Information
� 9
DesignerName: ����z�'�r-� `/n.v,Pr�i Phone: 7�5� -�9d -o >�9
Designer Address: �97D �?l,es>. S�. 5�,���L��_�C�� Zip: SY d'�d
E-mail: ���{fi�1�c�t`� C6'. {/O�—rl-�r`���. �a�v7 Tliisspacereservedfmapprovalstamp.
License Number: �,Z�j 3 s�Y
Remarks:
; �---
Signature: �1� � � � ; ' Date: ' �3
- Original signature required on each submitted copy.
CNBCK BOX I18APPLK`i1BLE. , i�t�l(BOX A8 APPIJCABLE
� � SOiL EVALUATION � � '�'�' � � ❑ SYSTEM PAGE Z OF
; SITE MAP � � PLOT PLAN
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P�T ADD� / �e �� 3� L�f� !%JC IdlG �72l P�e�/A�1$�1�d(Ted6S 384.�3�384.90-5�
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PAGE3OF4
HOLDING TANK SPECIFICATIONS
(No Scale)
Weatherpmof 12"Min.or 2 0 ft above
Junc[ion and APPro�� Established Flood Elevation
Alartn Bax Vent Cap (�YPical)
Elec[ncal must comply with 1 Approved Locking Manhole
SPS 316 and NEC 300 4"ID Vent Pipe � with Waming Label Attached
�Conduit >10 ft from (typical) 4"Min.or 2A ft above
Building � Established Rood Elevation
I , (rypical)
�Airtigh[Seal "
� Finished Grade
18"Min.
(�YPical) ..
a
Y
Inle[ InTletlnVert fWatertight
ApprovedJointswith . � Plug
Appmved Pipe 3 ft onto Maz.12"or 90%of to[al volUme
Solid Ground ' if more than one tank
d
Alartn-On
HOLDING TANK
VOLUME= J��i�% gal
a
3"Approved Bedding Ma[enal Beneath Tank
TANK MANUFACTURER: (�u f'tt-cf�— �—«G- _
�' 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)- Ibs]x 1.5= Ibs
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= ys� gpd
Insoection 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(sj 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 government unit in accordance wkh SPS 383.55 Wis.
Admin. Code. Report any component failure or malfunction to: Ly y �
// � � ) / ,� k
Name of individual or company: J�P y (,(/�,/ S�•<</i C�S �/ �'�E Phone: ��5 —.�3�/ ' 7>��
Local government unit: S � „ " �E C�c� v�� Phone: %�S— G 3$/ � �.� $�'
Local government unit address: /0 G� I� N1u•��/S s, �li�,,�,%:�r� �l l ZIP: � y �Y�
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.
Continaencv Plan ,
In the event that any failed component of this holding tank(s) cannot be repaired, it shali 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.
A �
e �
�" ,�, ,� Ft, <, .:
, � � �a
� � ���� � ,, Office of'
Sawyer County Zoning Administration
. 10610 Main Strcet Suite 49
�������� Hayward, Wisconsin 54843 ��
���R C p�l� (715)634-5288
��1/ .�I� FAX (71�)638-3277 �
� Q/ .1 I w�w.5awvucountvCo��.prg �j�
jtq� L — I� � E-mail: zonin � xc u'�sawvcrcount ov.org �� � ����
� � � \ = o � Toll Free Courthouse/General Information 1-877-699-4110 v O
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�� SAWYER COUNTY SANITATION DEPARTMENT �T�°N
TEMPORARY EMERGENCY TANK iNSTALLATiON APPROVAL
PROPERTY OWNERS NAME: �ctc-`.2,5 I"�aa S I
TOWN OF: ��yew��
ADDRESS: � I ��-(3S-W �n a �2. Lav��
I, +� _ _�v�� � � �QS� , a Wisconsin
Licensed Plumber, authorized by the owner, do hereby acknowledge that I am receiving
temporary approval to install a septic tank/holding tank without a soil and site evaluation,
or existing system evaluation, and private sewage system plan review due to inclement
weather and/or health and/or safety emergency.
Further, I acknowledge that a soil and site evaluation, or existing system evaluation, and
private sewage system plan review will be conducted by the deadline stipulated by the
permit issuing agent, or as soon as weather conditions or circumstances permit. If the
private sewage system is found to be failing as defined in s. DSPS 381 .01 (92), Wisc.
Adm. Code, corrective measures will be taken as such that the private sewage system
complies with all applicable requirements of chapter DSPS. 383, Wis. Adm. Code,
within 90 days of this agreement.
I further acknowledge that failure to comply by obtaining all necessary permits after the
deadline date may result in the issuing of a citation, under Section 11 .3 [2) Sanitary
Permits], of the Sawyer County Citati Ordinance.
DEADLINE FOR TH�S AGREE NT SHALL BE: ��l � � � �-3
� / ..---
a"v � • !
/ ± � �
Signed:�. K ' `
�
Date: �� '� � 2° �- 3
Accepted by: �h. ��%
Date of temporary emergency approvaL• �� l� ( � �- 3
Rev. 03/26/13
11/9123,11:54 AM Real Property Listing Page
Real Estate Sawyer County Property Listing Property5tatus: Current
Today's Date:11/9/2023 Created On:2/6/Z007 7:55:15 AM
�'Description Updated:10/2/2020 '�'l Ownership Updated:10/2(2020
._._ __._- -------___... .
TaxID: 8574 CHARLES HAASL ��� ���WISCONSIN
PIN: 57-008-2-37-09-17-5 OS-004-000230 RAPIDS WI
Legacy PIN: 008937175423
Map ID: :4.23 Billing Address: Mailing Address:
Municipality: (008)TOWN OF EDGEWATER CHARLES HAASL CHARLES HAASL
STR: 517 T37N R09W 7730 MEADOWLARK LN 7730 MEADOWLARK LN
Description: PRT GOVf LOT 4 IOTS 1&3 CSM 11/288 WISCONSIN RAPIDS WI 54494 WISCONSIN RAPIDS WI 54494
#2451
Recorded Acres: 1.060 �Site Address *indicates Private Road
Calculated A�res: 1.031 16435W ORIOLE LN BIRCHWOOD 54817
Lottery Claims: 0
First Dollar: Yes �property Assessment Updated:6/28/2021
Waterbody: Chetac Lake � �- �� �
2023 Assessment Detail
Zoning: (RRl)Residential/Recreational One Code Acres Land Imp.
ESN: 430
Gl-RESIDENTIAL 1.060 112,300 121,000
��Tax Districts Updated:2/6/2007 Z-year Comparison 2022 2023 Change
_____..__-- -
1 State of Wisconsin Land: 112,300 112,300 OA%
57 Sawyer County Improved: 121,000 121,000 0.0%
008 Town of Edgewater Total: 233,300 233,300 0.0%
650441 Birchwood School District
001700 Technical College
��Property History
�.�Recorded Documents Updated:10/2/2020 N�q �� ���� �-� �
TRUSTEES DEED
Date Recorded:9/28/2020 426755
TERMINATION OF DECEDENTS INTEREST
Date Recorded:8/13/2020 425673
QUIT CLAIM DEED
Date Recorded:4/17/2017 406206
QUIT CLAIM DEED
Date Recorded:9/7/2001 293926
WARRANTY DEED
Date Recorded:11/10/1986 Z02616
CERTIFIED SURVEY MAP
Date Recorded:10/16/1986 202258
https:l/tassawyercountygov.orglsystem/frames.asp?uname=Eric+Wellauer ���
HOLDING TANK SERVICING CONTRACT
Contract Date: � / � / ' C�.-s�
This contract is made between the Holding Tank Owner and the Pumper.
Holding Tank Owner's Name: Pumper's Name:
� �� ��� l,�s �-/� �s i � � � �� G_
� „� � S��v�r�s
� � , 1�-; �,
� �� t- /�d �-►�r �,
Parcel Identification Number:
(12 Digit Legacy ID) � � �t' - p' -� � - � � - J 5/ � �
1. The owner agrees to file a copy of this contract with the governmental unit, Sawyer County,
which has accepted and recorded with the Office of the Register of Deeds, the Maintenance
Agree�nent 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
pernut the pumper to have access and to enter upon the property for the purpose of servicing
the holding tank(s). The owner agrees to maintain the all-weather access road ar 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 Governmental Unit, Sawyer County, a report for the
servicing of the 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 holding 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 sites 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. In
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) / OWri@T''S S1g111tl1i'@: (Only one owner signature required)
� �C1r �P5 f'�GGat
� lr �
��
Pumper's Name: (Print) Pumper's Signature:
,� _ �vCy S�.u� v�z.c� �(- �1.�.� ��ir�.r. �owM-
Pumper's Registration Number:
� l �a
Rev. 03/26/13
s���iriis�.���i i�i i i�
� iii�
_.��-_;:�r_���G��
-USE BLACK INK ONLY - i x:4049333
4479�}5
POWTS MAINTENANCE AGREEMENT PAULA CHISSER
For Holding Tanks �EGISTER OF QEEDS
�AWYER COUNTY, WI
Owner's Name(s)as shown on deed: ��/Zg/2�23 08:45 AM
�2E�OR�.7ING FEE 3tt.00
C ��2�� S I� �� L
���Es: z
Parcel Identification Number: r t
(12 Digit Legacy ID) ���-�,��-F�- 7 ���
Legat Description of Property:
-SEE ATTACHED SHEET-
WeacknowledgethatapplipGonisbeingmadefortheinstaltationofaholdingtank(s)onthe _ _.
property described on the attached sheet. � � -
Return To:Sawryer Courtty Zorting artd Conservattott Admfrtistratfort Recording Area-Leave Blank per s.39.43(2m)
10610 Main St.,Suite 49,Hayward,WI 54843
As an inducementto the County of Sawyer to issue a sanitary permit for a halding 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 refating to holding tank management,including tfie 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 ho(ding tank properly serviced and to file a copy of the service contract wit�th e
governmental unit. The owner further agrees to file a copy of any changes to the service conVact,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 owneragreesto contract with a person licensed underCh.NR 113,Wis.Adm.Code,who sha11 submit pumping reports to
the govemmental unit in accordance with SPS 383.55,Wis.Adm.Code,forthe servicing of the holding tank. In the case of
exemption underSection 281.48(3)(d), Stats.,the ownershall submitthe report to the govemmental unit. The govemmental
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 govemmental unit to preven t
or abate a human health hazard as described in Secdon.254.59,Stats.,the governmental unit may enter upon the property
and service,or cause the tank to be serviced. Pursuant to 5ection 145.20(4)Wis.Stats.,a govemmentat 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,orofherwise servicing and maintaining the ho{ding tank in such a manner as to prevent or abate
any human health hazard caused by the holding tank.
4. This agreementwill remain in effectonly until the govemmental unit responsible for the regulation of private sewage system s
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 certificafion with reference to this
agreement in such mannerwhich will permitthe existence of the certitication to be determined by reference to the properly.
S. This agreementshall be binding upon the owner,the heirs of the owner,and assignees of the owner.The owner shell submit
the agreement to the register of deeds,and the agreement shatt be recorded by the register of deeds in a manner which witl
perm it the existence of the agreement to be determined by reference to the property where the holding tank is installed.
-On one owner si nature utretl- ACKNOWLEDGEMENT
Owne�' 'gnature• State of: 1/I/i�sn_o�s, ,�
�� � County of: �-�,�h��rn
Owne s ame (Print): Subscribed and swom to before me on this
' � ' ��� _ S�' day of 1�t'��r�bt. , 20¢�
Date: BY {owner) �y� � /
� �-� Notary Public Signatwe.
Drafted by: Notary Public Name:
���� � - ��'"'� �_ My commission expir�s . S-7'101�
Personal information you provide may be used forsecondary purposes[Privacy Law,§15.04(I)(m)] Rev.09/29l23
That part of Government Lot Four (4), Section 17, Township
37 North, Range 9 West, described as Lot One (1) and Lot
Three (3), as recorded in Volume 11 of Certified Survey Maps,
page 288-289, Survey #2451 , Document #202258.
` "'''�`r; PRIVATE ONSITE WASTE TREATMENT �ounty
����o$ ,, SYSTEMS Sawyer
�� p ' ( POWTS)
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r" `�` INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION 2'� _ 31g
Personal infonnation you provide may be used for secondary purposes(Privacy L,aw,s. 15.04(I)(m)J
Permit Holder's Name: ❑City ❑ Village �Town of: State Plan Transaction ID#:
G���.S 1-�q�sl �--� �r" �-
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Insp BM Elev: BM Description: Parcel Tax No:
( oa,�' Qo-{��-, b -Fs,�,,� 00�-937—(�7-�r�3
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic Benchmark �pp�p'
Dosing gl � � �, r
Aeration Bldg. Sewer �S 7 `
Holding y � St/Ht Inlet �`Y.O �
TANK SETBACK INFORMATI N St/Ht Outlet q3,g'
TANK TO P/L WELL BLDG VENT TO ROAD Dt Inlet
AIR INTAKE
Septic NA Dt Bottom
Dosing NA Installation
Contour
Aeration NA Header/Man.
Holding � � a` ` �a.�' 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/L Bldg We�� Waters � �GP ❑ Chamber
❑ AG ❑ EZFIow Model Number:
CELL TO ❑ Mound o Other
--- — -
- _ -- ----- -— ----
DISTRIBUTION SYSTEM X Pressure Systems Only
--- - -- � J
Header/Manifold Distribution Pipe(s) X Hole Size , X H e Observation Pipes
Length _ Dia �Length Dia Spac �� i Spacing ❑Yes ❑ No
- --- -— --
SOIL COVER
-— -- - —- _— --- ----- --
Depth Over Depth Over Depth of � Seeded/Sodded l Mulched �
Cell Center �Cell Ed es �
g 'i Topsoil __ ❑Yes ❑ No � ❑Yes � No
COMMENTS: (Include cotle discrepancies, persons present, etc.)
��,�,fl�,� �� ( �I�3
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,-�-; _� , - --
Plan revision required?❑Yes 0 No I , �, �
C � ��_''7J �- � — ___ �l ��
Use other side for atlditional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AOOITI�NAL COMMENTS ANO SKETCH
SANITARY PERMIT NUMBER: �� "'���
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