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INFORMAT*N & tNS`RUC(IONS FOCI COMP _FT!ll A, SAI'lil P'�r PERMIT
<br /> APPLICATION
<br /> TO THE APPLICANT:
<br /> 1. This sanitary permit is valid for two (2) years;
<br /> 2. Your sanitary permit may be renewed before the expiration date- and at the time of renewal any new
<br /> criteria In the Wlscons,n Administrative Code will be applicable.
<br /> B All 'evrsiors to this permit mast be approved by the perrf t sin rig ,.;ctv A new petront may e needed
<br /> 'f thee= is a change in your building plans, system oCut I C,11 rcflmat c W a;towater flow (number cf bed-
<br /> rooms, etc 1. depth os system, or type of system.
<br /> 4 Changes n ownership ttr plumber requires a Sanitary Pen+ if T,aOsiet Henew-t Foran ;SBO 6301At fo be
<br /> submitted to the county pror ,o :.staliation.
<br /> S Private sewage systems roust be properly maintained. The ar ptl C, iank!si mhould be pumped by a licensed
<br /> pumper whenever necessary. soapy every 2 to 3 years.
<br /> 6 If you have questions conn r. ,.y s,:,u, prvete sewage cyte f .,-a.L,,; yo_rr gar,, ua;e adn Iiatra; - o-
<br /> State of Wisconsin, Bureau of Plumbing, 608-266-3815
<br /> To be cornplete and accurate this sanitary permit application must Include
<br /> I Property owners flame and mailing address. Provide the legal descripCou ,vhere the system is to be
<br /> installed.
<br /> !I Type of building or use served If public is checked, indicate type of use (ie 10 unit apartment. 30 seat
<br /> restaurant. etc.) Fill in number of bedrooms if building is a one or two family dwelling.
<br /> Ili. Purpose of application. Check only one in #1. Complete #2 if permit is for tank replacement, reconnection or
<br /> repair,
<br /> IV Type of systemcheck all appropriate boxes depending on system type- Check experimental only If project
<br /> is in conjunction with University of Wisconsin,
<br /> V. Absorption systern information- Provide all information requested in #1-6'.
<br /> VI Tank information Fill in the capal of every now and/or existirry tar h, list the total gallons is oe a ed.
<br /> number of tanks and manufacturer's name. Indicate prefab or site constructad and tank mater.al Complete
<br /> for arise, lift siphon chamber ani' h�,Iding tanks for th,s system. Check (,xoerimental appr -roa` only if
<br /> tanks received expenmental product approval from DILHR,
<br /> VII Respg ,sithwiy statement Ir,,iallmg plumber is to fill In name. licensc numberr wdh appropriate '.e g.
<br /> MP, etc-), address and phone number. Plumber must sign application form Fill in designer name if
<br /> applicable,
<br /> V911- Snit test information'. Certified :;oil `,esters nam .. e. rfifica ion numbs od,ess. and (;hone r -1her.
<br /> IX. County/Department Use Only,
<br /> X. Comment area for use by county or resaon given when application Is disapproved
<br /> . ,.r' s�br t±rd to It - T;. -
<br /> ,�nmp'. to Diane ;9 r.CI SpeClilGdt-0nF; rIJ S't 1a!.++r l v'f P 1 I Ohl°[: n '�. .�....::..Y �.�.
<br /> plans fres` .ncl-,de 'he ;ciP,wrny_ AI ,1 ;',tan, d as,if to s a , _ w,t r i+4,it ! ,^ ,cs:wls .-.
<br /> ho!.dif 4 c(s:� qrl rat' s) ^t r
<br /> Sirean � at o IakPc dos:nrl , foumpnw, coamr,er3 disci:hoilotf it)", c[ nU>gr p[fnn 4vtii�m5 replat r,,,eM
<br /> - y`ter . d5 11te . , r1! '.h, , I , h - r> ' u vi cal ,l, , f IYl"I ..r -, nn nfc
<br /> CI cor ff-'te spacitications for pi and c:ontrclsdose von,meel,=vation differences- friction !oss, will
<br /> performance cwve: pump model and pump mart,f o trier, D) crass .,e.,iic:,n of the se:l ,t rt' seStl If
<br /> required by the county, Fj soil test data on a 115 form.
<br /> GROUNDWATER SURCHARGE
<br /> On May 4 1984 198-y Wisconslr Ar. 41G w ts ojlo tai- _;iw Ti,n w,i'
<br /> e
<br /> _ 'It of Jeer year_ ' �. J, .� ,_ r t _ " r_ _. ..wars _,_ arowtdw a76f --
<br /> rheti
<br /> "Its,.. Jr I;— used oy Your a.,rC'!I"I ;aft
<br /> I
<br /> watergr dwatef .or t't ra ,
<br /> its worth protecting
<br /> SPED 6398 (R.03,86)
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