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�- J /(,� I �� DANE COON hK- 32 5 1 DANE COUNTY X25 i, SANITARY PERMIT APPLICATION SEP 1 8 2009 PARTMENT OF HUMAN SERVICES • 4 Environmental Health Section •Attach complete plans for the system,on paper not less than 8'/z x 1 inches in.size, 12 2 Northport Drive,Madison,WI 53704-2088 nor more than 8'/x 17 inches in size. Public Health MDC Sa itary Permit Nbus2cetion •See reverse side for instructions for completing this application Environmental Health Personal information you provide may be used for secondary purposes[Privacy,Law,s. 15.04(1)(m)]. ❑Check if f�vision to prelfo Y P Y ryP rP State Plan Review Transaction Number I.APPLICATION INFORMATION — Please print all information Prope Owner Name AN ( I-k Lry PB ro pebj tion 5 / %, S i C° T G ,N, R & E Property Owner's Mailing Add ess Lot Number Block Number 'I z-5 di L - Pi L.1.- PD, 1 — City,State Zip Code Phone Number Subdivision Name• SM Number D Q- , w•i . e35 2- ( ) C-S ZYl 1`i 8 o ''LJ city II. TYPE OF BUILDING: (check one) ❑Village}OF: D.�r4� L:1 Public ...-Ts. Parcel Tax Number � / ,5}'1 or 2 Family Dwelling—No.of bedrooms__3 O z2_ -090R-- /6 '7 -- 9/90 z III. BUILDING USE: (if building type is public,check all that apply) 9 ❑ Office/Factory 1 ❑Apartment/Condo 5 ❑ Hotel/Motel 10 ❑ Outdoor Recreational Facility 2 ❑Assembly Hall 6 ❑ Medical Facility/Nursing Home 11 ❑ Restaurant/Bar/Dining 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 12 ❑ Service Station/Car Wash 4 ❑ Church/School 8 ❑ Mobile Home Park 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A.Check box on line B -..-,.. ---__ A) 1. ❑ New System 2. ❑ Replacement 3. ❑ Replacement • 4.-:'Reconnection of . ❑ Repair of an System Tank ik* Existing System Existing System B) q A Sanitary Permit was previously issued. Permit Number = Z `- - - •-• - i V. TYPE OF INSTALLATION OR REGULATED ACTIVITY ❑ Pump Chamber—Gravity I.G. ❑TerraliftTm Non Plumbing Sanitation System Privy ❑ Revision of Plumber ❑ Specify type ❑ Pit Privy ❑Vault Privy VI.ABSORPTION SYSTEM INFORMATION: For ReconJ .- -, • mber Transfer&TerraliftTm 1.GALLONS PER DAY 2.Absorp.Area Required 3.Absorp.Area Proposed g Rate(gals/day/sq.ft. 5.Perc.Rate(min./inch) 6.System Elevation(feet) 7.Final Grade Elevation (sq.ft.) Existing(sq.ft.) / (feet) 1450 ? i0 t o.g A 53 -- Ca.a.c4.ns Site VII. TANK INFORMATION Total #of Manufacturer's Name Prefab. Coe- Steel Fiber- Plastic N Existing aliens Tanks Concrete glass Ta s Tanks structed Septic Tank 090 i00,=, 1 m -./4-.0e- ar ❑ ❑ ❑ ❑ Lift Pump Tank/Siphon Chamber 5bc, 5 t / /'11 4,4--DE .8' ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT r❑the TerraliftTm process; I,the undersigned,assume responsibility for {l CI the installation of a privy or other non-plumbing sanitation system; the repair/reconnection of the POWTS or POWTS component(s);on the attached plans. NAME: t) SIGNA RE:(n lia s). MP/MPRSW/OTHER# Business Phone Number.Jew NI (� ( 1��- �s- z-z 0ti 106/97 <3 a3 PLUMBER'S ADDRESS:(street,city,state,zip code) F`D i Pj 7(o LeDi , Li�7. 5:3 5 IX. COUNTY USE ONLY _ , i Sanitary Permit Fee Date sue. ISSUIN • Yrei, •`'.=1411575�: . ❑Approved ❑Owner Given Initial �' ;I U Disapproved Adverse Determination 203 Jr, e =/;_ ._� �� X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPRO AL: / P s .4.�.f AJzr__-4 7 SO0.. 'Ire 1 _ 4 1 t4, 14o� D V S 1 �j111, -lit. — - 2■1 0P _IF , . 77 ' 6dab'0 ' , 231-248-15(4/01)