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INSTRUCTIONS <br /> I oantaryporm0isvalid t)' two (2) years. <br /> � soni&/ypu',ni/ /``a� hh*hrn \/1, e/,xaV"'- dale ap( ­.^ tc' timoo/ ,00v*'�! any :ow <br /> ,/.,r/omU'eVY.scocs" A:­iow I-akivrCode wdihsuppiicub|*. <br /> � ;�!| 'vviponoh |:npurmi� mw;thoap;ro,,cdtythe Permitissuing authority, <br /> � C�ungo, .: r-m/so,sh/po/ pl--mbr, r"qoiroouSso"-�r� Pe-nit T,ans4o//Roxovva! !,,m (SBD SJ09) tobe, <br /> oobm.Uo1Wthe county p/lv' toinstallation. <br /> � Onxi\osewage »yxIerInsmoo\ bep/oPo:ymaintained Thosrp�iv1ook(o| must beyoropndUyalicensed <br /> pumper whenever necessary, usually every 2to3years. <br /> 5. If you have questions concerning your onsite sewage system, contact your localcode adminiisiFahoror-the <br /> State v/Wisconsin, Safety & Buildings Division, h00-200'80l5. <br /> Tohocomplete und,auckra10this sanitary ponni1app|i�a1ionmust include: <br /> ~ <br /> | Property owner's name and mailing address. Provide the legal description and parcel tax nurfiber(s) of <br /> where the system iotoheinstalled. <br /> |i Type of building being served. Check only one and complete # of bedrooms if 1 or2Family Dwelling. <br /> U| Building use. 11 building type is Public, check all appropriate boxes that apply. <br /> IV. Type o/ permit. Check only one ioline A. Complete line 6 i permit iofor tank replacement, reconnection, vr <br /> repair. <br /> V. Type ofsystem. Check appropriate box depending onsystem type. <br /> VI. Absorption system information. Provide all information requested in #1-7. <br /> VII. Tank information. Fill inthe 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 D|LHR. <br /> VIII. Responsibility statement. Installing plumber iato fill inname, license number with appropriate prefix (e.g. <br /> MP, oto). address and phone number. Plumber must sign application form. <br /> |X. County/Department Use Only. <br /> X. County/Department Use Only. <br /> Complete plans and specifications not smaller than 0B ^ 11 inches must besubmitted tothe county. The <br /> plans must include the following: A) plot 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 o, 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 model and pump manufacturer; D) cross section of the soil absorption system if <br /> requiredby1he'Qoun1y; E) soi| tou1Uutuuna115form, undF) a|| nizinginformo1iun, <br /> --' '----'-'-'----'-'-'---'------------------------------'---------' <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 /> watercontnn`inadoninvootigod�ris'andostaNinAmentvf s1undands. <br /> . <br /> Soo-r000(m/w^ <br /> �� �� <br />