Laserfiche WebLink
Wisconsin Department of Industry, ONSITE SEWAGE SYSTEMS Office of Division Codes and Application <br /> - <br /> Onsite Sewage Section <br /> , Labor and Human Relations <br /> S201 E.Washington Ave.,Rm.141 <br /> Safety and Buildings Division <br /> PLAN APPROVAL APPLICATION P.O.Box 7969,Madison,WI 53707 <br /> (608)266-3815 <br /> INSTRUCTIONS: Please fill in all applicable data and submit this form with plans. Plans will not be reviewed until all fees are received. The <br /> reverse side of this form describes most of the required plan information. Further requirements may be contained in the Wisconsin Plumbing <br /> Code,which can be purchased from the Department of Administration, Document Sales and Distribution,202 South Thornton.Ave., P.O.Box <br /> 7840,Madison,W 153707,Telephone(608)266-3358. <br /> Plan Number Previously Assi <br /> 1. PROJECT INFORMATION(Type or print clearly) <br /> Name of Submitting Party(plansreturned tosame) Project1 Name ^ <br /> rgeA_u%n :1r s�-S6Y� 1—t 512 (JI Y1G� (R�Pa'Y1 <br /> Street Address,P.O.Box#or Rural Mte Project AAres or Legal Description <br /> • �i••O• Yom' x'lI <br /> City or Village State Zip Code City ❑ County <br /> O �� � Jr' 01 Village [3 of <br /> Telephon No.(iinclude area code) Town ❑ <br /> Designer Nameo Owner <br /> As i 50VIE eus✓Gnrrs� ne✓ <br /> Telephone No.(include area code) Telephone No.(include area code) <br /> 1115 - LOBS <br /> Street Address,P.O.Box#or Rural Route Street Address,P.O.Box#or Rural Route <br /> t{c,R 59 <br /> City or Village State Zip Code City or Village State Zip Code <br /> Obrt 2✓ �' <br /> 2. APPLICATION FOR: ❑ Experimental ❑ Mound System ❑ Holding Tank <br /> ❑ New Construction ❑ Large System ❑ Conventional Gravity System ❑ Groundwater Monitoring <br /> Replacement ❑ At-Grade ❑ System in Fill ❑ Petition For Variance <br /> ❑ Revision Pressurized System ❑ System in Flood Plain(attach SBD-6698) ❑ Other Alternatives <br /> 3. FEE COMPUTATIONS (include existing tanks) FEE SUBMITTED FOR OFFICE USE <br /> MAKE ALL CHECKS PAYABLE TO SAFETY&BUILDINGS DIVISION. <br /> a. 750- 1,500 gallon septic tank $ 50.00 <br /> b. 1,501- 2,500 gallon septic tank $ 60.00 60. 00 <br /> c. ,2,501- 5,000gallon septic tank $ 80.00 <br /> d. 5,001- 9,000 gallon septic tank $100.00 <br /> e. 9,001- 15,000 gallon septic tank 5150.00 <br /> f. Over 15,000 gallon septic tank $250.00 <br /> g. 500- 1,000 gallon dose chamber S 30.00 �APRJ_L149n <br /> h. 1,001- 2,000 gallon dose chamber S 50.00 <br /> 1. 2,001- 4,000 gallon dose chamber $ 70.00 AFFTY F o1Lti.Ti—^•l�(. <br /> j. 4,001- 8,000 gallon dose chamber $ 90.00 <br /> k. 8,001 - 12,000 gallon dose chamber $110.00 <br /> I. Over 12,000 gallon dose chamber $150.00 <br /> M. 500- 5,000 gallon holding tank $ 30.00 <br /> In. 5,001- 10,000 gallon holding tank $ 55.00 <br /> o. Over 10,000 gallon holding tank 5100.00 <br /> p. Revisions S 20.00 <br /> q. Groundwater Monitoring-Per Site $ 32.00 <br /> (other than a proposed subdivision) <br /> r. Petition For Variance: Setback S 25.00 <br /> Site Evaluation $ 50.00 <br /> Subtotal: <br /> S. Priority Plan Review: Enter same amount as Subtotal <br /> Total Fee: (� • O a <br /> SBD-6748(R.04188) NOTE:Fees are pursuant to Wis.Adm.Code,Chapter Ind.69,and OVER <br /> are subject to change annually. <br />