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:;;=; SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code CO NTY <br /> STAPERMIT <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than OGJI��/J\ <br /> 8%%11 inches In size. Check if revision to previous application <br /> -See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNERRROPERTY LOCATION <br /> John and Jennifer Sabatka NE '3a %, S 1 T40 , NIR 15 § (cl <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOC # <br /> 29770 Long Lake Road <br /> CITY,STATE ZIPCODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Webb Lake WI 54830 1 ( 715 ) 259-1107 <br /> Check one CITY NEAR ST ROAD <br /> If. TYPE OF BUILDING: <br /> ( ) ❑State Owned ❑ VILLAGE: Jackson Bay Road <br /> M ;OWNOF <br /> ❑ Public ®1 Or 2 Fam. Dwelling-#of bedrooms-3— PAR EL TAA NUMBER(S) <br /> 111. BUILDING USE: (If building type is public,check all that apply) c) 9,�o ` -O,- , <br /> 1 ❑ Apt/Condo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Out oor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Res taurant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Ser ice 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 KI 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 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.it.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 450 643 648 .69 NA 1 95.7 Feet 98.3 Feet <br /> VII. TANK CAPACITY Site <br /> inallons Total #of Manufacturer's rer's Name Prefab. Con- Steel Fiber- Plastic Exper. <br /> INFORMATION New xistin Gallons Tanks Concrete glass App. <br /> Tanks Tanks strutted <br /> Se ticTankorHoldin Tank 1 00 1 <br /> Litt Pump Tank/Siphon Chamber <br /> Vlll. 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: No Stamps) MP/MPRSWNl Business Phone Number: <br /> Wade Rufsholm 3361 715 349-7286 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 24702 Lind Road P.O. Box 514 Siren, WI 54872 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(includes Groundwater e u Issuing g 1 'gn t r IN mps) <br /> Approved ❑ Owner Given Initial j{ Il <br /> prpgarge Fee) <br /> Adverse Determination Jx�j )�-V <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.OB/93) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Own r,Plumber <br />