DCPZP-2009-00534 - Laserfiche WebLink

Home Browse Search

pg- 5Q L3 1' .. i l I II VI •DANA.'COUNTY Ch -5/GaG s �� I I 11 DANE COUNTY K ! •PARTMENT OF HUMAN SERVICES SANITARY PERMIT APPLICATION ' AUG 1 3 2009 Environmental Health Section •Attach complete plans for the system,on paper not less than 81A x 11 inches in size, 12C 2 Northport Drive,Madison,WI 53704-2088 nor more than 81/2 x 17 inches in size. Public Health MDC Sar itary Permit Number •See reverse side for instructions for completing this application. Environmental Health ] 0-73 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 14 iC.k(kg) Zia►vtik- NC '% NE %, s 3G T —7 ,N, R 1? E Property Owner's Mailing Address Lot Number Block Number 3R3 h,) )3W City,State Zip Code Phone Number Subdiaisiea-Naroe.or CSM Number C031/00fjoaR ( k.,.)�. 53573 ( ) 0361$ H. TYPE OF BUILDING: check one U City ( ) ❑Village I OF: El Public RI Town t?r �� 3 Parcel Tax Number al 1 or 2 Family Dwelling–No. of bedrooms ®? i 3 6 183 W b$ 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 U Restaurant/Bar/Dining 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 12 ❑ Service Station/Car Wash 4 U 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 applicable) A) 1. ❑ New System 2. ❑ Replacement 3. ❑ Replacement of 4. A Reconnection of 5. ❑ Repair of an System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF INSTALLATION OR REGULATED ACTIVITY ❑ Pump Chamber–Gravity I.G. 0 TerralifF Non Plumbing Sanitation System Privy ❑ Revision of Plumber ❑ Specify type ❑ Pit Privy ❑ Vault Privy VI.ABSORPTION SYSTEM INFORMATION: For Reconnection, Plumber Transfer&TerraliftTM 1.GALLONS PER DAY 2.Absorp.Area Required, 3.Absorp.Area Proposed 4.Loading Rate(gals/day/sq.ft.) 5.Perc.Rate(min./inch) 6.System Elevation(feet) 7.Final Grade Elevation (sq.ft.) Existing(sq.ft.) (feet) y 50 Ca aci in gallons VII. TANK INFORMATION New Existing Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Tanks Tanks Gallons Tanks Concrete structed glass Septic Tank l Ott, 1000 I •El ❑ ❑ ❑ ❑ Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT (❑the Terraliftm process; I,the undersigned,assume responsibility for {`0 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:(print) SIGNATURE:(no stamps) IS P/MPRSW/OTHER# Business Phone Number. 3e Wt.ty T LavNeke )vg--)7 �_.___ 773 2 920-nl- 25-6 -7 PLUMBER'S ADDRESS:(street,city,state,zip code) Pa box 666 Iak, /fli•II', r/1-AT 3 55l IX. COUNTY USE ONLY pproved ❑Owner Given Initial S itary Permit Fee Date Issued IS ,.,,�_;.LL AT�E no stamps) Adverse Determination- U -.•1 COUNTY ❑ Disapproved Adverse —'-' ��j 6 hr ��1,., %; to� , r� I• N�riFt•riftT- 1 mil- . n FSNInTk OLD ITSELF X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: LIABLE FOR ANY DEFECTS PLANS OR SPECIFICA- TIONS; PLAN OMISSIONS, _XA •INATION OVER- SIGHT, CONSTRICTION OR ANY nAnna,E TH T MA'y RESULT IN O.R.AFTER INSTALLATION AND RESERVES -T-HE P! T TO JRDLIl CI-1747RGE DR ADDiTIONS IONS SHOULD CONDITIONS ARISE MAKING THIS ,. , _.,. . al-248-15(4/01)