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SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm. Code COUNTv <br /> �,,4 A <br /> STAT(1906-)3 <br /> E SANITAR ERMIT#\\\_r q <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than l)&'d 6a� ObRcfCJ1'l <br /> 8%x 11 inches In size. ❑ Check if revision to previous application <br /> -See reverse side for instructions for completing this application. STATE PLAN I Nb�� <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. ) L - <br /> PROPERTVOWNER PROPERTY LOCATION <br /> Oak Ridge Partners -moi '/a '/a, S 9 T 41 , N, R 14 E(Or)W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT/�C\ �� BLOCK# <br /> 31453 Webb Lake Drive ��// <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Danbury, WI 54930 715 259-3346 qq <br /> 11. TYPE OF BUILDING: (Check one) ❑ State Owned CITY <br /> LLLAGE We Lake N N R WebbA take Drive <br /> ®Public 1:11 or 2 Fam. Dwelling,#of bedrooms_ PARER <br /> LTAX NUMBER(S) <br /> 111. BUILDING USE: (If building type is public,check all that apply) <br /> 1 ❑ Apt/Condo ` v <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 EX Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining <br /> 4 ❑ Church/School 8 ® Mobile Home Park 12 ❑ Service Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify <br /> IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. ® New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.❑ Repair of an <br /> System System Tank Only Existing System Existing System <br /> B) ❑ A Sanitary Permit was previously issued. Permit# Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 E4 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank <br /> 12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy <br /> 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy <br /> 14 ❑ System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1.GALLONS PER DAY 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 15. PERC.RATE6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 800 1143 1296 .62 NA 91.8 Feet 94.3 Feet <br /> VII. TANK CAPACITY Site e.inallons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdin Tank 2.0 2.000 1 Skald <br /> Lift Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plumber's Signature:(N tamps) MP/MPRSW No.: Business Phone Number: <br /> Wade Rufsholm � e�T� 3361 715 349-7286 <br /> Plumber's muure5s(Street,City,State,Zip Code): <br /> 24702 Lind Road P.O. Boa 514 Siren, WI 54872 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing Agent Signa re NoS mps) <br /> VKA rovedreharge Fee) <br /> pp ❑ Owner eDeermial ^O <br /> Adverse Determination J 6 <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety 6 Buildings Division,Owner,Plumber <br />