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• <br /> DANE=COUNTY DANE COUNTY <br /> SANITARY PERMIT APPLICATION DEPARTMENT OF HUMAN SERVICE: <br /> Environmental Health Section <br /> •Attach complete plans for the system,on paper not less than 8%x 11 inches in size, 1202 Northport Drive,Madison,WI 53704-208t <br /> nor more than 8%x 17 inches in size. sanitary Permit Number <br /> •See reverse side for instructions for completing this application. <br /> Personal information you provide may be used for secondary purposes[Privacy,Law,s.15.04(1)(m)J. ❑Chedc if revision to previous application <br /> State Plan Review Transaction Number <br /> I.APPLICATION INFORMATION—Please print all information <br /> Property Owner Name Property Location <br /> l n'tij OF one Par Ls Commission tA) % ScC y., S 3S T 0f0 ,N, R QD E <br /> Property Owner's Mailing Address Lot Number Block Number <br /> I Pc-41 au- C oL&t <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> YYla i son VI 5_31i S (lGo?)2(.6-Le <br /> city <br /> II.TYPE OF BUILDING: (check one) o°■ e}OF: <br /> ®Public ®Town UQI0n0. <br /> Parcel Tax Number <br /> ❑ 1 or 2 Family Dwelling—No.of bedrooms O(.o0 B- 352 - q t)00 - q <br /> Ill. BUILDING USE: (if building type is public,check all that apply) 9 ❑Office/Factory <br /> 1 ❑Apartment/Condo 5 ❑Hotel/Motel 10 3 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 ❑Terraliirm Non Plumbing Sanitation System Privy <br /> ❑Revision of Plumber ❑Specify type ❑ Pit Privy ®Vault Privy <br /> VI.ABSORPTION SYSTEM INFORMATION: For Reconnection,Plumber Transfer&Terralift • <br /> 1.GALLONS pER DAy 2.Absorp.Area Required 3.Absorp.Area Pronoasd 4.Loading Rate(gals/day/sq.1L) 5.Pere.Rare(minJInch) 6.System Elevation(feet) 7.Final Grade Elevation <br /> (sq.IL) I (NA) Beet) <br /> VII. TANK INFORMATION N in es Total sot Manufacturer's Name Pry Con Steel P'ber- Plastic <br /> Tanks Tanks Gallons Tanks Concrete strutted glass <br /> Septic Tank ZOO ZvoO ) IrQS-i ii10000 , <br /> Lift Pump Tank/Siphon Chamber.... ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT ❑the TerraliftT"process; <br /> I,the undersigned,assume responsibility for ❑the installation of a prnry or other non-plumbing sanitation system; <br /> • e /reconnection of the POWTS or POWTS component(s);on the attached plans. <br /> NAME:(print) SIGNA ) MPIMPRSW/OTHER i Business Phone Number <br /> Seel^ Gassr ,na.n L i i ...>� �- a a 3 a 4 3 I goof?) 43'1-BSa a <br /> PI UMBER'S ADDRESS:(street.city,state,zip code) <br /> 11 O) 4 adc hat k. Ori e_, C.. e 1V lou \Lt.% YS i'- <br /> IX. COUNTY USE ONLY <br /> ❑Approved ❑Owner Given Initial Sanitary Permit Fee pats Issued ISSUING AGENT SIGNATURE(no stamps) <br /> ❑Disapproved Adverse Determination <br /> X.CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> 231-248-15(4701) <br />