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INSTRUCTIONS
<br /> -,ar;:ta!y pp,n) , IS aiir' f, !veo i2i ,ea-s.
<br /> sar I at y ", r T%,t i 'iW�) t4,- !� ", ',! ', ' -: I Iii'
<br /> dry nPw
<br /> ,,ocria in the Niscons r to s r cs Cr)-19 w,il A,
<br /> onthis Fe-'1i &j,i;c)rtty.
<br /> A. Changes in ownership or 7equires a San;ark Pl,!rrir t 7r4,,qf-r,Ren(oviih i-,,m !SRD 6399; to ne
<br /> S'Aunlitted !o the collpj'y plaor to rl5tti I
<br /> CL Onsite sewage systems be i. peY y inaintained The septt,- hroe�, fnust be pumped by P !tensed
<br /> pumper whenever necessari., usually every 2 to 3 years
<br /> 6. If you have questions concerning you, onsite sewage system, contact your local code administrator or the
<br /> State of Wisconsin, Safety & Buildings Division, 608-266-381-5.
<br /> To be complete and accurate this sanitary permit application must include
<br /> I Property owner's name and mailing address Provide the legal description and parcel tax number(s) of
<br /> where the system is to be installed.
<br /> 11. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
<br /> 111. Building use. If building type is Public, check all appropriate boxes that apply.
<br /> 1V Type of permit. Check only one in line A Complete line B if permit is for tank replacement, reconnection, or
<br /> repair.
<br /> V Type of system. Check appropriate box depending on system type.
<br /> VI Absorption system information Provide all information requested in #1-7
<br /> V11 Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of
<br /> tanks and manufacturer's name Indicate prefab or site constructed and tank material. Complete for all
<br /> septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received
<br /> experimental product approval from DILHA.
<br /> Vill, Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g.
<br /> MP, etc ), address and phone number. Plumber must sign application form.
<br /> IX County/Department Use Only.
<br /> X. County/Department Use Only.
<br /> Complete plans and specifications act smaller than 8/2 x 11 inches must be submitted to the county. The
<br /> plans must include the Vlowing A) plot plat), drawn to scale or with corniplerte dimensions, location of
<br /> holding tank(s), septic tank(s) or other treatment tanks tu;lding sewers wells, water mains/water service:
<br /> streams and lakes pump or siphon tanks; distribution boxes. soil absorption systems, replacement system
<br /> areas, and the location of the building served, 8) horizontal; and vertica! elevation reference points,
<br /> Q complete specifications for pumps and controls, dose volume; elevation differences; friction loss; pump
<br /> performance curve, pump model and pump manufacturer; D) cross section of the soil absorption system if
<br /> required by the county, E) soil test data on a 115 form, and F) all sizing information.
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<br /> GROUNDWATER SURCHARGE
<br /> 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of
<br /> regulated practices which can effect groundwater.
<br /> The monies collected through these surcharges are used for monitoring groundwater, ground-
<br /> water contamination investigations and establishment of standards.
<br /> SBD-6398(R,11/88)
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