HomeMy WebLinkAbout012-740-16-1101-SAN-1990-234OAMITADV OCQRAIT ADoll lr%-ATlft1k1
R
COUNTY
In accord with ILHR 83.05, Wis. Adm. Code
CST 90-265
SAWYER
STATE SANITARY PERMIT# .
-Attach complete plans (to the county copy only) for the system, on paper not less than
151018
8% x 11 Inches in size.
❑ Check If revision to previous application
-See reverse side for instructions for completing this application.
STATE PLAN I.D. NUMBER
I. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. • e
PROPERTY OWNER
PROPERTY LOCATION
a
-% ,&%,S T D,N,R W
OP TY OWNER'S MAILING ADDRESS
LOT III
BLOCK #
CI , STATE
ZIP CODE :
PHONE NUMBER
SUBDIVISION NAME OR CSM NUMBER
ko�d—f,j"V /ij.i
It. T#PE OF BUILDING: (Check one) ❑ State Owned VIIW4GE - NEAREST ROAD
de
4.
❑ Public tD 1 or 2 Fam. Dwelling-# of bedrooms
III. BUILDING USE: (If building type is public, check all that apply) 012 - 740 -16 -1101
1 ❑ Apt/Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recrgational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash
5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. ❑ New 2. Replacement 3. [1Replacement of 4. ElReconnection of S. ElRepair of an
Psystern
System Tank Only Existing System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit ## — Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non -Pressurized Distribution Pressurized Distribution Experimental Other
11 Seepage Bed 21 ❑ Mound 30 El SpecityType 41 ❑ Holding Tank
e
12 Seepage Trench 22 ❑ In -Ground 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy
14 ❑ System -In -Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
REQUIRED (sq. fL) PROPOSED (sq. ft.) (Gals/day/sq.1L) (Min./inch) ELEVATION
Feet Feet
VII. TANK
INFORMATION
CAPACITY
In allons
Total
Gallons
# of
Tanks
Manufacturer's Name
Prefab.
Concrete
Site
Con-
Steel
Fiber-
glass
Plastic
Exper.
App.
New stin
Tanks I Tanks
structed
Septic Tank or Holdin Tank
O
Lift Pump Tank/Siphon Chamber
El
Vill. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Print):
Plu=nature:
MP/MPR6aAFN6.:
Business Phone Number.
Plumbs r Address treet, C , State. Zip Code)
IX. COUNTY/DEPAR ENT USE ONLY
Approved
Disaproved
lHownper Given Initial
Sanitary Permit Fee (Includes Groundwater
Surcharge Poo)
Date IssuedI
111-8-901
Agent Signature (No Stamps)
Adverse Determination
$115.00
X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL:
SBD-8:tf18 (formerly Plb4M (R.111981 DISTRIBLMON- Orialnal to County_ Ono Cnnv To- Satoh & Rulldinna nivialnn. Owner_ Rlumhar
i
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DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING _
LABOR & HUMAN RELATIONS DIVISION y
P.O. BOX 7969 ON -SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION
MADISON. WI 53707 State Plan I.D. Number
CONVENTIONAL ❑ ALTERATIVE (11assigned)
❑ Holdinq Tank ❑ In -Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER!
ADDRESS OF PERMIT HOLDER:
INSPECTION DATE:
-90
BE C AR (Par anent reference Point) DESCRIBE IF DIFFERENT FROM PLAN:
FIEF. PT. ELEV.:
C T REF. PT. ELEV.:
Name of Plu bar:
MP/MPRSW No.:
County:
Sanitary Permit Number:
Q
) —
rJ=i��Jri d.��l�/l�r.\�.11:1 ►ri l.��I�d
MANUFACTURER:
LIQUID CAPACITY:
TANK INLET ELEV.:
TANK OUTLET ELEV.:
WARNING LABEL
LOCKNG COVER
reGpS 7�
Od
%
�J
I 7 7 S
PROVIDED:
1 Off YES ❑ NO
PROVIDED:
❑ YES ❑ NO
BEDDING:
VENT DIA.:
VENT MATL.:
HIGH WATER
NUMBER OF
ROAD:
PROPERTY
WELL:
BUILDING:
VENT TO FRESH
ALARM:
FEET FROM
LINE:
r
7,
AIR INLET:
❑ YES ❑ NO
❑ YES ❑ NO
NEAREST��
-
7rS
- - - - ----
PROVIDED: PROVIDED:
❑ YES ❑ NO I I I ❑ YES ❑ NO ❑ YES ❑ NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL BUILDING VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET:
PUMP ON AND OFF ❑ YES ❑ NO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil,moisture at the depth of plowing FORCE LENGTH: DIAMETER: I MATERIAL AND MARKING:
or excavation. (11 soil can be rolled into a wife, construction shall cease until MAIN
the soil is dry enough to continue.)
(`nhIVF1JTlnN01 CVCTFM-
BED/TRENCH
WIDTH:
LENGTH:
NO. OF
DISTR. PIPE SPACING:
COVER
INSIDE DIA.:
N PITS:
LIQUID
TRENCHES:
MATE IAL:
FIT
DEPTH:
DIMENSIONS
GRAVEL DEPTH
FILL DEPTH
DISTR. PIPE
DISTR. PIPE
DISTR. PIPE MATERIAL:
NO. DISTR.
NUMBER OF
P
L:
UIL IN :
VENT OFRESH
BELOW PIPES:
ABOVE COVER:
ELEV. INLET:
ELEV. END:
PIPES:
FEET FROM
LINE: 7
r
I
ZS
AIR INLET:
/[�
%
Al o�
NEAREST �♦
%Sa
7
7z r
MOUND SYSTEM:
Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM
slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW
❑ YES ❑ NO meets the criteria for medium sand. ELEVATIONS MEASURED.
SOIL COVER I TEXTURE: I PERMANENT MARKERS' I OBSERVATION WELLS:
❑ YES ❑ NO ❑ YES ❑ NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL SODDED: SEEDED: MULCHED:
CENTER: EDGES:
❑YES El NO ❑YES ❑ NO ❑ YES ❑ NO
BED/TRENCH
WIDTH:
LENGTH:
NO, OF
LATERAL SPACING:
GRAVEL DEPTH BELOW PIPE:
FILL DEPTH ABOVE COVER.
TRENCHES:
I
DIMENSIONS
MANIFOLD
PUMP
MANIFOLD
DISTR. PIPE
MANIFOLD MATERIAL:
NO. DISTR.
DISTR. PIPE
DISTRIBUTION PIPE MATERIAL & MARKING:
ELEV.:
ELEV:
DIA.:
ELEV.:
PIPES:
DA,:
ELEVATION AND
I
I
DISTRIBUTION
HOLE SIZE:
HOLE SPACING:
DRILLED CORRECTLY:
COVER MATERIAL:
VERTICAL LIFT CORRESPONDS TO
INFORMATION
APPROVED PLANS
❑ YES ❑ NO
❑ YES ❑ NO
COMMENTS'
PERMANENT MARKERS:
OBSERVATION WELLS:
NUMBER OF
OPERTY
WELL:
BUILDING:
L
❑ YES ❑ NO
❑ YES ❑ NO
NEAREST -
Sketch System on
Reverse Side.
SBD-6710 (R. 06/88)
� 21
Retain in county file for audit.
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