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ihi5�'�1JGT�t3RE <br /> __ _ 91r P . _ _ p <br /> - _ _,al am row <br /> o r 1't . <br /> .$ e '✓M <br /> 10f1ty. <br /> 50 4'j C4 .h .e'S� �.gGires •e ue <br /> r L.'diter` , liI pr or nsai;aur.; <br /> n !rn sewage sys±em ,.reey .,..cd "e se,�' ^ rirkfs -n.;st n6 p;.mped by a Licensed <br /> pumper whenever necessary, �:sua:Py weary 2 tc 3 years. <br /> r1,. If you have questions concerning your onsite sewage system, contact your local code adm!nistrator or the <br /> State of Wisconsin, Safety & Buildings Division, 608-266-3815. <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 /> ll. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. <br /> III. Building use. I1 building type is Public, check all appropriate boxes that apply. <br /> IV. 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 /> VII. 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 a// <br /> septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received <br /> experimental product approval from DILHR. <br /> VIII. 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 not smaller than 8'/, x 11 inches must be submitted to the county. The <br /> plans must include the following. A; p'ot plan, drawn to scale or with complete dimensions, location of <br /> holding tank(s), septic tank(s) or other treatment tanks, building 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: B) horizontal and vertical elevation reference points; <br /> C) complete specifications for pumps and controls, dose volume; elevation differences: friction loss'. pump <br /> performance curve; pump m del and pump manufacturer, D) cross section of the soil absorption system if <br /> required by the county; E) soest data on a 115 form; and F) all sizing information. <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) <br />