DCPZP-2009-00064 - Laserfiche WebLink

Home Browse Search

• , ,.TY ' 1 ,.._ E .___ .._ _.. !i; DANE COUNTY . �; ` s [ PARTMENT OF HUMAN"'l3ERVICES Y PERMIT APPLICATION 2009 ) Environmental Health Section •mplete plans for the system,on paper not less than 844.4.11 inc �in size, —4202 Northport Drive,Madison,WI 53704-2088 ore than 8%x 17 inches in size. _j Sanitary Permit Number e reverse side for instructions for completing this application .i1e ; , ,, C 70 (0 l Personal information you provide may be used for secondary purposes[Privacy;taWN:-15:04(•6(m)j:'':_"_.__. ❑Check if revision to previous application State Plan Review Transaction Number I.APPLICATION INFORMATION —Please print all information Property Owner Name Property Location /� / + if r Ja61-PS (9Cc'i )JeC 6i�eI q-1^ raeni`, irt.4 't .5-Lk/ % 5(-,-, A S 33 T Oct ,N. R 0 E Property Owner's Mailing Address / 1�A a.L Lot Number Block Number 6 /O5 i-ndt• scc,nyJl,eiC- XS 1.------ - City,State Zip ode Phone Number Sub 'vision Name or umber Oane LA) 5-35-a1 ( ) o City II. TYPE OF BUILDING: (check one) ❑Vivage}oF: -� ' DAAi r i®Town I) _ ❑ Public Parcel Tax Number ® 1 or 2 Family Dwelling—No.of bedrooms (�?DP—'3 3 3— r .y hI1_ $oci 3 �� 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 applicable) A) 1. ❑ New System 2. ❑ Replacement 3. ❑ Replacement of 4. X 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. ❑Terraliftn' 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 1 (sq.ft.) Existing(sq.ft.) (feet) 6 0 0 ____ _ (---- Capacity in gallons Site VII. TANK INFORMATION New Existing Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic Tanks Tanks strutted Septic Tank [ (,, l f/ ea y '� ❑ ❑ ❑ ❑Lift Pump Tank/Siphon Chamber /60 / ',,„ a - ®. ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT ❑the Terralift1' process; I,the undersigned,assume responsibility for • the installation of a ivy or other non-plumbing sanitation system; 2 •air/reco e n of the POWTS or POWTS component(s);on the attached plans. NAME:(print) ,r• 8- t”mps) MP/MPRSW/OTHER# Business Phone Number. 5fe tJeat K Crosby f �-?oo GO) ?Y4 - k-7� 7 PLUMBER'S ADDRESS:(street,city,state,zip de) -7 3G ( aa,_ li� c_f= caz.e cu]: .5-35-2-e/ IX. COUNTY USE ONLY -Approved ❑Owner Given Initial Sanitary Permit Fee Date Issued q7 EN Ul ENT SIGNATURE(�ostamps) ❑Disapproved Adverse Determination �3 • on 3 �— �WGR,INTING T AP ,� `"�� ENVIRONMENTAL HEALOE HOLD SE X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: LIABLE FOR ANY DEFECTS IN PLANS OR SPECIFIC. TIONS, PLAN OMISSION�MINATIUN OVER- SIvHT, CONSTRUCTION OR ANY DAMAGE TH4T M/, RESULT IN Op Ar—CR.WS IALLATION AND RESERVE } ; 1titaHT TO ORDER CHA NC r+Cae+...., p ,T s ARISE MAKIN r:T ube.- , .. ,C_ it r •)•11-/A14-1 A4!n11 .. . I /l I ,i r I�. (AL