The URL can be used to link to this page

Home My WebLink About002-940-23-5112-SAN-1988-240SANITARY PERMIT APPLICATION COUNTY QDILHR In accord with ILHR 83.05, Wis. Adm. Code SAWYER STATE SANITARY PERMIT # CST 88-270 l —Attach complete plans (to the county cop only) for the system, On paper nQ(QBSs than ,. CS'j r "'o STATE PLAN I.D. NUMBER ' 8%x 11 inches in size. /7 7/9 /VU Ot K's. ,0 7 -See reversesidefor instructionsfor completingthis application. P/0 L• PETITION ❑YES ❑N I. APPLICANT INFORMATION —PLEASE PRINT ALL INFORMATION q—+ FORVARIANCE PROPERTY OWNER PROPERTY LOCATION '/a, S T D, N, R (or) W PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME 1 S L , X17 CITY, STATE ZIPCODE PHONE NUMBER CITY NEAREST ROAD, LAKE OR LANDMARK VILLAGE: TOWN OF If. TYPE OF BUILDING OR USE SERVED: OOd - Number of Bedrooms if 1 or 2 Family OR ❑ Public (Specify): o III. PURPOSE OF APPLICATION: (Check only one In ifl. Check H 2,3 or 4, If applicable) 1. a. New b. ❑ Replacement c. ❑ Replacement of d. ❑ Reconnection of e. ❑ Repair of an System System Septic Tank Only an Existing System Existing System 2. ❑ A Sanitary Permit was previously issued. Perri Date Issued 3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements. 4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy. IV. TYPE OF SYSTEM: (Check only one in Q1 and only one in q2) 1. a. ® Conventional b. ❑ Alternative c. ❑ Experimental 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d.❑ Vault Privy e. ❑ Mound I. ❑ IGP In -Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Checkons) 1. a. Xseepane Bed b. ❑ See a e Trench c. ❑ Seepage Pit 2. PERCOLATION RATE 3, ABSORPTION AREA 14, ABSORPTION AREA 5. SYSTEM ELEVATION 8. WATER SUPPLY: (Minutes per inch): REOUIRED(Square Feet): PROPOSED (Square Feel): / U /O %(�5 Feet 10PrIveis ❑Joint ❑Public VI. TANK INFORMATION CAPACITY in allons Total Gallons qol Tanks Manufacturer's Name Prefab. oncrel Site Con- Steel Fiber- glass Plastic Exper. App New isgn Tanks Tanks strutted Septic Tank orHoldin Tank ?Te Lift PumpTank/SI hon Chamber '00 VIL RESPONSIBILITY STATEMENT I. the undersigned, assume responsibility for installation of the private sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) MPANilbil e.: Suelnesa Phone Number: / . / -�3 S-9.r Plumber'& Address l tree(, City, Stale, Zip Coda: Name of Designer Vill. SOIL TEST IINFORMATION Certified Soil Teeter (CST) Name CST's ADDRESS st ads, City. Slate. Zip Code) Phone Number: IX. COUNTY/DEPARTMENT USE ONLY l-L Disapproved Sanitary Permit Fee EiAppraved ❑Owner Given initial SlIr; water surcharge Fea ate 1 g Agent Signature(No Stamps) verse Determination $90.00 $25.00 10-18-88 X. COMMENTS/REASONS FOR DISAPPROVAL: SBD-6388 (formerly PIbAr) R. D3/8e) DISTRIBUTION: Original to County, One Copy To: Bureau of Plumbing, Owner, Plumber INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT APPLICATION TO THE APPLICANT: 1. This 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 Cade will be applicable: 3. All revisipns to this permit must be approved by the permit issuing authority. A new permit may be needed it there is a change In your building plans, system location, estimated wastewater flow (numbef, of bed- rooms, etc ). depth of system, or type of system: 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. Private sewage systems must be properly. maintained. The septic lari should be pumped by a licensed purnper whenever necessary, usually every 2 to 3 years: 6. It you have questions concerning your private sewage system. contact your local code administrator or the State of Wisconsin, Bureau of Plumbing, 608-266-3815. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing adtlress. Provide the legal description where the system is to be installed: 11. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.), Fill in number of bedrooms if building is a one or two family dwelling; III. Purpose of application: Check only one in $1. Complete 42 if permit is for tank replacement, reconnection or repair; IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project is in conjunction with University of Wisconsin: V. Absorption system information: Provide all information requested in $1-61 VI. Tank information: FIII in the capacity of every new and/or existing tank, list the total gallons to be installed, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material Complete for all septic, lilt/siphon chamber and holding tanks for this system. Check experimental approval only If tanks received experimental product approval from DILHR; VII. 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. Fill in designer name if applicable; VII(. Soil test information: Certified soil tester's name, certification number, address. and phone number. IX. County/Department Use Only; - X Comment area for use by county or resaon given when application is disapproved. Complete plans and specifications not smaller Ihan 814 x 11 inches must be subm ltted to the county The plans must include the following: A) plot plan. drawn to scale or with complete dimensions, location of holding lankis), septic tanks) or other treatment tanks; building sewers, wells: water mains/water service: streams and lakes; dosing or pumping chambers; 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 ditterencss: 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 GROUNDWATER SURCHARGE On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more commonly known as the groundwater protection law. This change in statutes was the result of over 2 years of steady negotiation and public debate. The groundwater bill Ground star — included the creation of surcharges (fees) for a number of regulated practices which Wjsco in'S' can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that bu riedIrreasure is used in your building is returned to the groundwater through your soil absorption System or the dlspos if si t"sed by your holding tank pumper. The monies collected through these surcharges are credited to the groundwater fund adminis- Ve tered by the Department of Natural Resources. These funds are used for monitoring ground- '^ water, groundwater contamination investigations and establishment of standards. Groundwater, it's worth protecting. seo 630 IR-03/961 v, O &,,v,eR 5I`� � �,r, /�� :ems-4_45 4 Po �32 Jihu��'r�e AIV 6' pre Mir 1 TOWN OF BASS LAKE SEC.23 TWP 40 N. R. 9 W. P, ROAD GOSS : /. 7 NOT USE p 5)(J.2 'a CERTI FI ED SURVEY MAP AM j kfllJtt'r1WlGi1{ Gi� 1 . 76 lill 2f, OuW14k10 4040 ._ (294C 4 W(A 4M of 610 (46. 4*6V &I U i1 . gw,4 .ttw I�orNt Mitt It yA;,A t3 . %0 ffNt� 4lNh1Id0M . �1 lOtMEY �'�4.23 k : tol 14 eta 4100 Pratl 0 M644 IN (7Gtb L�olVtMt till , � G 22� r 000 roo i� p� o A..10 61, OSA. 4/— 0166 axis% eio & Of "lit � 1'0.0. t/•d ri�C y l • �6KeFt4 �S+Iot1VEtt6�i �oVKa 44 mid y a. • 9W10 a ltq,l id 16A NY 4a4 to.,1.40 1W.10) `s, 1 (JOAW4 a VIA1!r YVAYAJ Vttlt Wt ttAt favivi y rtQ�ymw 6 41C �lA hic of �j6rr�toyt t3, tint Cos. ti9ynlwlt� �o' bG9Y No�kk $�'•hD'•22• �1a�k �f � W .1 N 7L <w /loo.rrntNo 00 Ism L'iA 0 Gana �¢ etklot� egg-.0.Ik rft 0 o ho too too Y DAVID F. • $ ' J� I� Q� RIEDER uu * S•1737' Pa�ca �tbdar ? BIRCHWOOD�,}'Erbb lsNb �ur�tyo�r x y'% ��,.�,,,, y0�� k�lgtaut5iV1 (Zag.#�•Ig3'I OLZI 10001 lim t t 1k 6& 6w EotrytfAf of Aivi. LOY t --I ft~ "1-3 %J 141 44014 Q yo