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CANE 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,W163704-2081 <br /> nor more than 8%x 17 inches in size. Santry 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)I. ' 0 Check if revision to previous application <br /> State Plan Review Transaction Number <br /> I.APPLICATION INFORMATION—Please print all information <br /> Property Owner Nam Property Location <br /> 0Orte NA) % n LA) Y.. S 54 T O6 .N. R I I E <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 1 Fen Oak Cou r-€ <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> (fad.l 50n . (/t?I 6311 I$ (bog ) z -9'19 9 <br /> city <br /> II.TYPE OF BUILDING: (check one) O wags}OF: rt Prat,i - <br /> On Public a Town <br /> Pascal Tax Number <br /> ❑ 1 or 2 Family Dwelling—No.of bedrooms Q 5'2)/ Q$1 i 3.4-2.— 85co -1- <br /> III. BUILDING USE: (if building type Is public,check all that apply) g ❑Office/Factory <br /> 1 ❑Apartment/Condo 5 ❑ Hotel/Motel 10 Si 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. ❑TerraliRTM Non Plumbing Sanitation System Privy <br /> ❑Revision of Plumber ❑Specify type ❑Pit Privy ®Vault Privy <br /> VI.ABSORPTION SYSTEM INFORMATION: For Reconnection,Plumber Transfer&Terraliftni <br /> 1.GALLONS PER DAY 2.Absorp.Area B.1940g 3.Absap•Area rP noosed 4.Loading Rats(galsldaylsq.R) 5.Pere.Rate(miNlnch) S.System Elevation(fese'7.Final Grade Elevation <br /> MA-) Wan(eq•I) (rest) <br /> VII. TANK INFORMATION Ca it t1ons Taal iof Prefab. Site i <br /> Fiber- <br /> ."" '''"""11 anks Gallons Tanks Manufacturer's Name Concretes Steel glass Plastic <br /> Septic Tank 200O 200 1 !fir al ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber.... ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT 0 the TerraliIrm process; <br /> I,the undersigned,assume responsibility for l 0 the installation of a privy or other non-plumbing sanitation system; <br /> ❑th pair/ nnedion of the POWTS or POWTS component(s);on the attached plans. <br /> NAME:(mint) . Matter <br /> MP/MPRSW/OTHER i Business Phone Nuer: <br /> Serf aSSinan as 3a4 3 (o0g)437-7ad <br /> PLUMBER'S ADDRESS:(street,city,state,zip code) <br /> 1 i o 14 ZAac u.k.. QT- elikL m o(mod WI 5350. <br /> IX.COUNTY USE ONLY <br /> O Approved 0 Owner Given Initial Sanitary Permit Fee Data Issued ISSUING AGENT SIGNATURE(no stamps) <br /> 0 Disapproved Adverse Determination <br /> X.CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: . <br /> 231-248-15(4101) <br />