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INS"'RUCTUONi <br /> | A saMta/ypo/n.itirValid lwo (2) you/s <br /> � a !"o /iwoo[ r,'.owa| uny "vw <br /> sirux/voCode wo| ooapplicable, <br /> � r^vi,|un; u �his ;+r"i/ rxu,," 53* op;/vvod 1,;ythe po/m.tiuuoir/0aujhvo/y <br /> � Cha:_�ooi, _` y/oml:',/ �oqu./oomSamzv// pa�eqT/ansfe//-vnovvy| Form (8Br)V�?09) tvbo <br /> submitted to. the oountyprior \oinstallation. <br /> > 0nsitysewage systems must topropor!ymu(1tu|n^dThe septic tunk(s) must hopumped byu !iconooU <br /> pumper whenever necessary, usually every 2 /o3years. <br /> 0, If you have questions concerning your onsite sewage system, contact your local code administrator or the <br /> State ofWisconsin, Safety 8Buildings Division, 608'205'3V15. <br /> To be complete and accurate this sanitary permit application must include, <br /> |. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of <br /> where the system in1oAoinstalled. <br /> || Type of building being served. Check only one and complete # of bedrooms if I or 2 Family Dwelling. <br /> |||. Building use. If building type is Public, check all appropriate boxes that apply. <br /> IV. Type odpermit. Check only one inline A. Complete line Oifpermit infor tank rop|aoemont' reconnectionu, <br /> repair. ' <br /> V. Type o( system. Check appropriate box depending oosystem type. ' <br /> VI. Absorption system information. Provide all information requested in #1-7. <br /> VII. Tank information. Fill inthe capacity o{ every new and/or existing tank, list the total gn||oounumber o/ <br /> tanks and manufacturer's name. Indicate prefab orsite 000skuot*dand tank mutnha|, Complete for all <br /> septic, pump/siphon and holding tanks for this systern. Check experimental approval only if tanks received <br /> experimental product approval from 0LUR. <br /> Vill. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. <br /> MP, otc)' 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 0& « 11 inches must be submitted tvthe covnty The <br /> y|ansmusXinc|uUotho /n||ovving: A) p|vtp|an, druwnt000e|oo, withoomp|etodimonoi000, |oca1ion � <br /> of <br /> holding iank(s)' septic tank(o) orother treatment tanks <br /> I building sewers; vve||o; water mains/water service; <br /> otroamnanU |akos; pumporsipkonionko; disXhsystem <br /> areas, and the |ooah ` <br /> ono/thebui|din0norvod� B) horizontu| onUvor�i�u| o|�va\ionro{or�n�opoin�u� <br /> C) complete op*ri/ioad `ono/orpumpnandcoo�rv|�� d000vn/umo� o|�va1ionUiVooenco�� hi��ion |vos. , ; 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. <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 /> water contamination investigations and establishment of standards. <br /> SBO-6398(R nxm> <br /> � � <br />