HomeMy WebLinkAboutWillow River
'LHR SANITARY PERMIT APPLICATION COUNTY
sus In accord with ILHR 83.05, Wis. Adm. Code
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than ` f
8t% z x 11 inches in size. El Check if revision to previous application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPERTY OWNER PROPERTY LOCATION
t/a %,S T , N, R _f (or) W
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD
State Owned ❑ VILLAGE :
❑ Public ❑ 1 or 2 Fam. Dwelling-# of bedrooms - AR EL AX NUMB R( )
III. BUILDING USE: (If building type is public, check all that apply)
1 ❑ Apt/Condo
20 Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
40 Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash
5 ❑ Hotel/Motel 9 ❑ Office/Factory j 13 ❑ Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. Q 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 Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 220 In-Ground 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 43 Q Vault Privy
14 ❑ System-In-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
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION
Feet Feet
VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holdin Tank F1 I [I
Lift Pump Tank/Si hon Chamber
VIII. RESPONSIBILITY STATEMENT
1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Print): Plumber's Signature: (No Stamps) MP/MPRSW No.: Business Phone Number:
Plumber's Address (Street, City, State, Zip Code):
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No Stamps)
Surcharge Fee)
❑ Approved ❑ Owner Given Initial
Adverse Determination
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD41398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety8 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 `tis permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SSD 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 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the
State of Wisconsin, Safety & Buildings Division, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of
where the system is to be installed.
11. Type of building being served. Check only one and complete of bedrooms if 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 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 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 (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'h 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; close 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)
i
' V
y O 1/1
-10 w
h h y C 1
m ° 0
..V, h m y U~ W
m C w 'Cj a z
3 y 'y o 'g l~ m 0~
~ c 0,v ~ a 4
E o
U \ f\
b m>
0 ° y ° 0
Qt 3 ¢ ` u l
cm
m O t a 49 %-j
2 o
1\ , o -0 T C
cr.
W ° h
O O
d d U c: -a .-..0 cWi C C -
4Z
z Ig x "7-
CC y = x C
° ~ a ° o [ o - c
z w ti o a~ m
o a
'y Q O vUmi :-r w .0
0
co) z m
LLI v cc Q m m~ 3 e w F 0 rn D
O c 0-? w
LL. G y s
W e C7 3 m° a Itm
H H
U Z = a ti 0 0 a° W t-
2 •O
ate} o~ 4.
~ J z m •o
Z ~a 0 oy oz m
Z UI \ k d 'n N N y 3
m Lu W O w 3 w .a
<m
C 0
_
O C N O w° 0
J m p ac ° o°
m
-j S
~ m z om0 y w ~ 0 ~ ~ « F
a
a
y
e
U 0
R e~ d y U b 3 F
Z
w
O w
a> > m
2 c s° B c ° \ Y 0
d C 11 tl
U e ,o c Y c eo a 0 E m
u a S c ° A 0 m o m -
o a
> •y w
E .S rn ❑ ° c
-S CO 4;
e 0. ° e ° 0 L F
b \ o c s
a0 ° ° 0 0 ai x o
an 3 ° b ' > 0 m C\'
V 3 m .5 :3 A c v v v H
w N U w O y y .C.
O a C~ m m yo a: m y 00
o p m m m E
h d p A Am = Z m -
e m s a c m e S u~
E z ---t m '3 .2
:3 -0 CN
cm -0 3 3 3
° 0 Z
r c= 3 E N v
0
Ni U E
y
0 LL
w F U G 0. p 0. N H G is C)
Cl?
0 o =
Q u o A t t s z t H
3 z 3 F F o F° F F
O a Q
a O
c -6 c c w
d
I -'o
f ~
c 2 0 Ic 0.
o o m. a o f 2 o
~ a
o m E o f y Q
it
m cQ
w
c O
V ~ U E
s E 0 ,r 0 0• > o
H EdN o v`0
Q 3 a ° d o > m o d
H ~ O ~ n7 •O .D ` a C .ice
N _
_Z O p .'n y c i Q
N 0 Y - C O w
z -.2 N O. v - N y? .
3L -
y E C.. a o-°« a «V ~ 0 E'o (COMM
Z > E E E OR O
oc >op -T
c >
y > V> LL
Lei 1 a) „ N40 Ho d'o w ) E NMW
c 0
rL°, E c m
E Y o; E Y d
OC o o y ° E 10 a' a
°
o y o. 0 m 3~ 3 « a,c a E O
LLJ I- dd m~ (ou Q
Oc ym W J
4 a o m>:g? T oa' o
E m~ c
Q a„ ° m- v ;
2 ~m am 'cELd oo m'.r c~ v
-0 m m y m m
U am ma) NO~c c ~d Nm 0m w
L _
t a N > W
y
d a) C 10 'E - c a+ a)
L N 'L L - ~ c L- a) L O Q ~ i
a O d - W
c
F"0 H~c_ U~ ~m~ f d -Q 7 F-
^m d E!
Z
d
2 0
to a O N O a~ "O a: O N y a I w r- m Z w Z
Z LL L) CUD °
O U Q `L U) Z
O O U
U U) o f d1wo D
> > LL
U) F
CO U)
Z o 0 z
Z U) N 00
W Ir U
O
U Q = Z
J U U Q a
° f- ° o0
J ` Ir
LL
W
Q ~ J
INC
U U) m
w
cw Ir >
a CL
~ X
W
COO*
Ir LL
W.
O
ao °C m O w
co z 0-
~ ~
CUD
m _w z =
0 d- Q co