012-740-02-1112-SAN-1990-232SANITARY PERMIT APPLICATION
jZdILHR.,_,,,...v In accord with ILHR 83.05, Wis. Adm. Code
CST 90-259
-Attach complete plans (to the county copy only) for the system, on paper not less than
8% x 11 Inches in size.
-See reverse side for instructions for completing this application.
I. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
L
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V
STATE SANITARY PERMIT #
151015
❑ Check if revision to previous application Dul
STATE PLAN I.D. NUMBER W
S90-20846 191
PROPERTY OWNER PROPERTY LOCATION
T `/o , N, R E or W
PROPERTY OWNER'S MAILING ADDRESS ILOT# BLOCK #
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
t
II. TYPE OF BUILDING: (Check one) ❑ State Owned VILLLLAGE : NEAREST ROAD
II ��II u�
LZ Public ❑ 1 or 2 Fam. Dwelling-# of bedrooms _ PARCEL TAX NUMBER(S)
Ill. BUILDING USE: (if building type is public, check all that apply) 012- 740-02-1101 fit 1102
1 ❑ Apt/Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home
3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs
4 ❑ Church/School 8 ❑ Mobile Home Park
5 ❑ Hotel/Motel 9 ❑ Office/Factory
10 ❑ Outdoor Recreational Facility
11 ® Restaurant/Bar/Dining
12 ❑ Service Station/Car Wash
13 ❑ Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line S if applicable)
A) 1. ❑ New 2. ® Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
System System Tank Only Existing System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit # Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non -Pressurized Distribution
11 N Seepage Bed
12 Seepage Trench
13 ❑ Seepage Pit
14 ❑ System -in -Fill
Pressurized Distribution
21 ❑ Mound
22 ❑ In -Ground
Pressure
Experimental
30 ❑ SpecifyType
Other
41 ❑ Holding Tank
42 ❑ Pit Privy
43 ❑ Vault Privy
VI. ABSORPTION SYSTEM INFORMATION:
1. GALLONS PER DAY
2. ABSORP. AREA
3. ABSORP. AREA
4. LOADING RATE
15. PERC. RATE
6. SYSTEM ELEV.
7. FINAL GRADE
REQUIRED (sq. ft.)
PROPOSED (sq. ft.)
(Gals/day/sq. ft.)
(Min./inch)
ELEVATION
9,00
VSl 0
7s-
Feet
Feet
VII. TANK
CAPACITY
in allons
Total
# of
Prefab.
Fiber-
FExr.
INFORMATION
latin
Gallons
Tanks
Manufacturer's Name
oncret
oSteel
e,,
Site,
glass
PlasticNew
.
Vlll. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Print): Plumber's Signature: (N tamps) MP/MMPRS/W No.: Business Phone Number.
o' C�
Plumber's Address (Street, City, State, Zip Code).
/?f 1 AA / a..z LtJ.,'At -4-01.- Wlr .Sc,(e,01
IX. COUNTY/DEPARTMENT USE ONLY -
❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued I =Agenture (No Stamps)
JE] Approved ❑ Owner Given Initial t Surcharge Fee)
�, ,�115, o0 11-s-9o_2��
X. CONDITIONS OF APPROVAUREASONS FOR DISAPPROVAL:
SBD4W8 (formerly Pib-67) (R.11188) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
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 will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be
submitted to the county prior to installation, -
5 Onsite sewage systems must be properly man talned. The septic tanks) must 66 pumped by a licensed
pumper whenever necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the
Stale of Wisconsin. Safety & Buildings Division, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
I. Property owner's name and mailing address. Provide the legal description and parcel lax number(s) of
where the system is to be installed.
li. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
III. Building use. It building type is Public, check all appropriate boxes that apply.
IV Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or
repair.
V. Type of system. Check appropriate box depending on system type.
VI, Absorption system information. Provide all Information requested In #1-7.
VII. 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 far alif
septic, pump/siphon and holding tanks for this system. Check experimental approval only it tanks received
experimental product approval from DILHR.
Vill, 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 ii 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 tanks) 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 bythe county E) soil,testdata on a 115 form; and F) alllsizing information. _ _
GROUNDWATERSURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (less) for a number of
regulated practices which can effect groundwater.
The monies collected through these surcharges me used for monitoring crou.;uvalei, giow:d-
water contamination investigations and establishment of standards:
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