DCPZP-2009-00029 - Laserfiche WebLink

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Monday, February 23, 2009 2:34 PM Chris Miller Construction(608)877-1367 p.03 F . r DANE COUNTY DANE COUNTY DEPARTMENT OF HUMAN SERVICES SANITARY PERMIT APPLICATION Environmental Health Section •Attach complete plans for the system,on paper not less than 81/2 x 11 inches in size, 1202 Northport Drive,Madison,WI 53704-2088 nor more than 8%x 17 inches in size. Sanitary Permit Number •See reverse side for instructions for completing this application. ,ZO -1 5 o-g. 706,0 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 2 Property Owner Name Property N y Location J��.1 /, S y� T N, R (Q E%vaRo-f-- `1 mes Iz.E Property Owner's Melina Address Lot Number Block Number 329 5 LEE sen.)-ck.t CT. City.State Zip Code Phone Number Subdivision Name CSM Number h•NC-CAe—t_p(a 0 m 1.4 I 5355 S ((oo$) $38-=731 1 ` ll 4 lJ City l II. TYPE OF BUILDING: (check one) javiiliapeIoF: Fs L.0:3,-,., J G�Ye ❑Public Town Parcel Tax Number )5K1 or 2 Family Dwelling—No.of bedrooms 008 '" 0 7 I o -3c.3 - OrDsc5"' 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,if a,• • - • - • A) 1. ❑ New System 2. ❑ Replacement 3. ❑ Replacement of , of •. ❑ Repair of an System Tank Only Existing System Existing System /fj/ B) A Sanitary Permit was previously issued. Permit Number °� � 1/4-A -- - sued f/ gk3 V.TYPE OF INSTALLATION OR REGULATED ACTIVITY ❑ Pump Chamber—Gravity I.G. UTerraliftl'A Non Plumbing Sanitation System Privy ❑ Revision of Plumber ❑ Specify type ❑ Pit Privy ❑Vault Privy VI.ABSORPTION SYSTEM INFORMATION: For Reconnection,Plumber Transfer&TerralittTm 1.GALLONS PER DAY 2.Absorp.Area Reeuired 3.Absorp.Area Esmond 4.Loading Rate(galsldayisq.R.) 5.Pen:.Rate(min/cinch) 6.System Elevation(feet) 7.Final Grade Elevation (sq-R-) MOM(sqA) (feet) 450 1125 .r- I - e , ¢ fo(p I - o 95.0 VII. TANK INFORMATI• N'w Total N Pr Site Tas Galons Tanks Manufacturer's a Con Steel Plastic Septic Tank loco fasa 1 W'PR-v6v E zr4 ❑ ❑ ❑ ❑ Lift Pump Tank/Siphen-Cherber.... 640 Lao / V A t.r'^A ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT f❑the TerraliltTM process: 1,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) I MPIM PRSW I OTHER I Business Phone Number: 1 K f A S e(M aA 1A,A_ J L.G -- -z-/ 7& 6ok- i3 9-3/ 6/ PLUMBERS ADDRESS:(street,city,state,zip code) /" d. 610 Y'-- e2-43 Co+4gt r C�toire, 53521 _ IX.COUNTY USE ONLY Permit Fee' Pe anrm Date I acid ISSUI AGENT St ..ePproved ❑Owner Given Initial S cc, El Disapproved Adverse Determination 4e i. '� X. cONDITI NS OF APPROVAL/REASONS FOR DISAPPROVA } �� AI D L� �7 O1 6,0 ,,,,Q1&--7---c.,..1 1 & , C GR N4 • P ill it - et.....1n1 _ -4 tr• .&r.!(c- 231-248-15(4/01) (3_1IS-2$\ /x-`11 C - —."