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• .. DANE COUNTY UANt COUNTY SANITARY DEPARTMENT OF HUMAN SERVICES ANITARY PERMIT APPLICATION Environmental Health Section •- •Attach complete plans for the system,on paper not less than 8%x 11 inches in size, 1202 Northport Drive,Madison,WI 63704-2088 nor more than 8%x 17 inches in size. Sanitary Permit Number •See reverse side for instructions for completing this application. - O ii 1* Personal information you provide may be used for secondary purposes[Privacy,Law.s. 15.04(1)(m)]. ❑Check if revision to previous application State Plan Review Transaction Number I.APPLICATION INFORMATION —Please print all information Property Owner Name (� Property Location !v e t L. 17'j CH rkiE L. ,/`!lE % /v w %. s Imo- T S .N. R e E Property Own•rr's Mailing Address Lot Number Block Number ( -7o 1-1-L-4i`1 I q City.State Zip Code Phone Number Subdivision Name or CSM Number W-Arv✓Pr , wl Ss3S'ci'7 (6oT ) Os--110:- II.TYPE OF BUILDING: (check one) u0 Village}or ❑ Public [�i"own 5 1° (Z w C._�t$E—L..0 Parcel Tax Number 2 Family Dwelling—No.of bedrooms 3 2/ - ogo? - I 2.-2_ -)3 3 6o - 0 III. BUILDING USE: (if building type Is pu 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,if applicab ) A) 1. ❑ New System 2. ❑ Replacement 3. ❑ Replacement o "-'-4.: econnection of 5. ❑ Repair of an System Tank Only [I :Ek dling'System l Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number f Date Issued i i V. TYPE OF INSTALLATION OR REGULATED ACTIVITY APR 2 2 2004 ❑Pump Chamber—Gravity I.G. ❑Tenerife', Non Plumbing Sa elation System._ _______. privy ❑ Revision of Plumber ❑ Specify type _ r' 1 r'' .U Pit rivy ❑Vault Privy " VI.ABSORPTION SYSTEM INFORMATION: For Reconnection,Plumber Transfer&Terraliftr' 1.GALLONS PER DAY 2.Absorp.Area Rewired 3.Absorp.Area• .... • 4.Loading Rate(gals/day/Wt.) 5.Perc.Rate(minit ch) 6.System Ekvadon(feet) 7.Final Grade Elevation (sq.N.) Existing(sq.1L) (feet) L—I C17 !aiD q 0 0 o. > //-1.6' /16• o ' VII. TANK INFORMATION ciP2°t�'"°aeons Total X a per_ Site Fiber- -eel Tanks Taman Gallons Tanks Manufacturers Name Concrete s Cori- Steel glees Plastic Septic Tank /4 x o /o 04) I C.-a-t S T" L I V C I L I C I U Lift Pump Tank/Siphon Chamber etirsy ‘o 6 00 ! c-a-i S•: U—' ❑ ❑ _ ❑ ❑ VIII. RESPONSIBILITY STATEMENT r O the TerralifPu process; I,the undersigned,assume responsibility for Sl❑the installation of a privy or other non-plumbing sanitation system; ❑the repaidreconnection of the POWTS or POWTS oomportent(a);on the attached plans. NAME:(print) SIGMA 21/0 MPIMPROW/OTHERS Business Phone Number J(,IA0 Rib.", '-S / r/ 3 7 3 2 C07)C s--f3aC-- PLUMBER'S ADDRESS:(street,city.state,zip code) • 3.> vin Pro AR Lu-'Ls-rVJ-J L w( .S act t/ ( r}-2c,wG-nr.l t-4,Arevt,v4r� Cv-, t,vc.,) / , ,,a , VT. •F(34;r11 IX. COUNTY USE ONLY ,i.,, +,_ii lir±t.]J It''k.F Approved ❑Owner Given Initial Permit Fee Date Issued ISSUt ENT S I G N A T U R E I i f:A- Approved Disapproved Adverse Determination Lt 2..- 4-= i`��' . mo t U ,n i ;,t T FHA I-MAY X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: ti _',r,;tl.:'a,�;l1 11.'•n.illiUN5 li•l!: .r r'iFii, Its 231-246-15(4/01)