2007/08/21 - SANITARY - SAN - Other (3)

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INSTRUCTIONS 1- A sanitary permit is valid for two (2) years 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code wi!: be app!icab!c. Ali revisions to this permit must be approved by the permit issuing authority. 4. Changes In ownership or plumber requires a Samfary r ermit Transfer/Renewal Form (SBD 5399) to be submitted to the county prior to installation. 5 Onsite sewage systems most he properly mamtained. The septic tanks) must be pumped by a licensed PU whvnev@r iiecussa'y, c3i'aiiy eve!y tic � peat,. " if you have questions concerning your onsite Sewage system, contact your local code admmistr Wor dr the State of Wisconsin, Safety & Buildings Division 608-2Fi6-3815 To be complete and accurate this sarntaiy permit application, rnust include Property owners name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. I Type of budding being served. Check only one and complete 9 of bedrooms i` 1 or 2 Family Dwelling. III. Building use. If building type is Public, check all appropriate boxes that apply. Iv. Type of permit. Check only one to line A. Complete line B it permit is for tank replacement, reconnection, or repair. Type of system_ Check appropriate box depending on system type- V! ,Absorption system information. Provide all information requested In #1 7. VI!. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X County/Department Use Only. Complete plans and specifications not smaller than 8'/z x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers, wells, water mains/water service, streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form, and F) all sizing information. ------------------------------------------------------------------------------------------------------------------------------------------------- GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD-6398(R_11/88)