HomeMy WebLinkAbout014-280-00-0400-SAN-1990-225O A L1IT A nV I15Cta \SIT A total I^ A grl^Ll
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1) DI
COUNTY
In accord with ILHR 83.05, Wis. Adm. Code
CST 90-253
SAWYER
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than
151008
8% x 11 inches In size.
❑ Check If revision to previous application
-See reverse side for instructions for completing this application.
STATE PLAN I.D. NUMBER
I. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPERTY OWNER
h ICt+A4E L_ V:- AU I_V.A rzR
PROPERTY LOCATION
55 Y. SW Y., S 35 T 40'c N, R or W
PROPERTY OWNER'S MAILING ADDRESS
897+ S'fCANORE LkµE
LOT #
UNiT +
BLOCK #
CITY, STATE
HAPLIS GmvE M1`4
ZIP CODE
155%69
PHONE NUMBER
N'SCiinlEIOERS
SUBDIVISION NAME OR CSM NUMBER
-TP%LL PftAws QO r4bb
II. TYPE OF BUILDING: (Check one) 1-1StateOwned ��� : LE�R�-r- NEAREST aono
❑ Public X1 or 2 Fam. Dwelling-# of bedrooms UMBER(S)
Ill. BUILDING USE: (If building type Is public, check all that apply) 014-280-00-0400
1 ❑ Apt/Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash
5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify
IV. TYPE OF PERMIT: (Check only one In line A. Check line B if applicable)
A) 1. ❑ New 2. eplacement 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 Pressurized Distribution Experimental Other
11 XSeepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 ❑ In -(around 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy
14 ❑ System4n-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
REOUIR�D( (sq. ft.) PROPOSED (sq. %) (Gals/day/sq. ft.) (Mintch) C78.. I ELEVATION
mot' o� "" 1 Feet Feet
VII. TANK
INFORMATION
CAPACITY
In allons
Total
Gallons
# of
Tanks
Manufacturer's Name
Prefab.
Concretestructed
Site
Con-
Steel
Fiber-
glass
Plastic
Exper'
App.
New
istin
Tanks
I Tanks
Se tic Tank or
00 0
0 0
FTI
LIK Pum Tank/Si hon Chamber
00
El
.
1:1
Vlll. RESPONSIBILITY STATEMENT
1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Print):
PI bees Signature: (No Stamps)
MP/MPRSW No.:
Business Phone Number:
�'so
Plumber's Address Street, City, State, Ztp Cod
_' x fol RY W A RD W..i S q$� 3
IX. COUNTY/DEPARTMENT USE ONLY
® Approved
❑ Disapproved
❑ Owner Given Initial
Sanitary Permit Fee (includes Groundwater
surcharge Fee)
Date Issued
Iss(Wgent Signature (No Stamps)
I Adverne Determination
$115.00
10-30-90
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R.11/86) 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 dale, 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 maintained- The septic tank(s) must be 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
State of Wisconsin. Safety 8 Buildings Division, 668-266-3815. -
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 tax numbers) of
where the system is to be Installed.
II. Type of building being served. Check only one and complete'# of bedrooms if 1 or 2 Family Dwelling.
III. Building use, II building type is Public, check all appropriate boxes that apply.
IV. Type of permit, Check only one In line A. Complete line 8 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 j11-7.
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 for all
septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received
experimental product approval from DILHR.
Vill. Responsibility statement. Installing plumber Is to fill in name, license number with appropriate prefix (a. 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% 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 tl flarences: friction loss: pump
performance oyrve; pump model and pump manufacturer; D) cioss seo"un of the snll absorption syslum if
required by-tFe county; E) soirtest data on a 115 form; and F) all sizing miornialion.
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 monitoa'ing 9i ouudwater, ground-
" - -water contamination investigations and establishment of standards.
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