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DANE COUNTY DANE COUNTY <br /> PO <br /> SANITARY PERMIT APPLICATIONRECEIVE D DEPARTMENT OF HUMAN SERVICES <br /> Environmental Health Section <br /> •Attach complete plans for the system,on paper not less than 8%x 11 it 4i(1t;;14 1202 Northport Drive,M dl on,WI 63704-208 <br /> nor more than 8%x 17 inches in size. San Pe t Nu —•See reverse side for instructions for completing this application. Public Health MDC + e <br /> Personal informs p�V n taI i Pe <br /> information you provide may be used for secondary purposes[Pi1v8�i,C-�iv, T5.t74 ]. ❑Check if revision to previous application <br /> State Plan Review Transaction Number <br /> I.APPLICATION INFORMATION—Please print all information <br /> Property 9rer, me �`�� Property Location c n 7' A I w 'i' &V1/+� -PG)kr 5O✓\ 7w % E +/., S i�J T 9 ,N, R ! E <br /> Property s Address Lot Number Block Number <br /> 5 T t 2-70 2Z <br /> CAI%State Zip Code Phone Number Subdivlalon Nf, g14pm , G,'L- (^)x- 55976 ((O 1 -6 / 0W 14114 Q <br /> II. TYPE OF BUILDING: (check one) <br /> -1:3 city }OF: <br /> , , Ropbw <br /> ❑ Public Parcel Tax Number <br /> . '1 or 2 Family Dwelling—No.of bedrooms LI 050 `09 cr /63 — .6/32 0 <br /> III. BUILDING USE: (If building type Is public,check all that apply) 9 ❑Office/Factory <br /> 1 ❑Apartment/Condo 5 ❑ Hotel/Motel 10 ❑ Outdoor Recreational Facility <br /> 2 ❑Assembly Hall 6 ❑Medical Facility/Nursing Home 11 ❑ Restaurant/Bar/Dining <br /> 3 ❑Campground 7 ❑ Merchandise: Sales/Repairs 12 ❑ Service Station/Car Wash <br /> 4 ❑Church/School 8 ❑Mobile Home Park 13 ❑Other:specify <br /> IV. TYPE OF PERMIT: (Check only one box on line A.Check box on line B,If applicable) <br /> A) 1. ❑ New System 2. ❑ Replacement 3. ❑ Replacement of 4.*Reconnection of 5. ❑ Repair of an <br /> System Tank Only Existing System Existing System <br /> B) ❑ A Sanitary Permit was previously issued. Permit Number Date issued <br /> V.TYPE OF INSTALLATION OR REGULATED ACTIVITY <br /> ❑Pump Chamber—Gravity I.G. ❑TerraiifP Non Plumbing Sanitation System Privy <br /> ❑Revision of Plumber ❑ Specify type ❑ Pit Privy ❑Vault Privy <br /> VI.ABSORPTION SYSTEM INFORMATION: For Reconnection,Plumber Transfer&TerralifVM <br /> 1.GALLONS PER DAY 2.Absorp•Area Reituked 3.Absorp.Area Precosed 4.Loading Rate(gals/daylsq.IL) 5.Pero.Rate(min./inch) 8.System Elevation(feet) 7.Final Grade Elevation <br /> (sq.n.) ESxls log(Nil.) (feet) <br /> 4000 SYsT1 ._#4 <br /> VII. TANK INFORMATION Capacity ingallons Total sot Prefab. Site Fiber- <br /> New Tnks ETenksg Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic <br /> strutted <br /> Septic Tank ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT r 0 the Terralift"1 process; <br /> (,the undol''e i�n.ed„msume sponsibility for {`0 the installation of a privy or other non-plumbing sanitation system; <br /> Grt �G u/!7 er the repair/reconnection of the POWTS or POWTS component(s);on the attached plans. <br /> (P;iM) a pJ� SIGNA : o mps MP�/MPRSW/OTHER 8 Business Phone Number.G <br /> PLUMBS :( ei L z-� �j(/6 (Uy�2 t<x� <br /> 0SO I� KOCUl C o h S*c, loft S5 7 v <br /> IX. COUNTY USE ONLY <br /> ' Approved 0 Owner Given Initial S ermtt Fee Date Issued ISSU ENT SIGNATURE(no ps) <br /> 0 Disapproved Adverse Determination ` �• 4_eo-4S , <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> 231-248-15(4/01) <br />