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INSTRUCTIONS
<br /> A, sanitary perrn vai;d 'wo (2) years
<br /> yc:jr sanitary pp,-i!t " a -'ewe,
<br /> ewj dry new
<br /> cute r
<br /> is in :lie :--e appi,a
<br /> Vis.ORS 1C, tf'
<br /> owrie,,frip o, P,,,:t
<br /> +C n(_.
<br /> r,-MPc! Ic- the couniv. pn,.!,
<br /> Onsite sewarjie. syslei"s il-_" bf. orf,'ne.;Ypi,lorj he se[, , he pumper by a icer,„Q'j
<br /> pumper whenever rieceFsa:y. ,sual!y every 2 to 3 yea,s
<br /> 6 If you have questions concerning your cnStto sewage Fvstern, contact y,,,,jr ocai code adrn-nistrator er 0'e-
<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 /> 11 Type of building being served. Check only one and complete # of bedrooms if I or 2 Family Dwelling
<br /> 111. Building use. If building type is Public, check all appropriate boxes that apply.
<br /> IV. Type of permit. Check only one in line A. Complete line 6 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 arid/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 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 riot smaller than 8/, , 11 inches must be Submitted to the 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, budding sewers weds, 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 verfica� 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; P) 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.
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<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.11188)
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