DCPZP-2009-00179 - Laserfiche WebLink

Home Browse Search

May, 5. 2009 1 :45A M _ /37 �, < 1ILg] No,' G ......�.__ ..`_._1_ 0433 P 1 DANE COUNTY Ch — ' 0 V r . -_ ''..I .: DANE COUNTY SANITARY PERMIT APPLICATI ! ,.,1 !II DEPARTMENT OF HUMAN SERVICES MAY 4 2009 ,r! Environmental Health Section •Attach complete plans for the system,on paper not less than %x 11 inches in size, ''-'" 1 1202 Northport Drive,Madison,WI 53704-2088 nor more than 8%x 17 inches In size. ..., ...... - i Sanitary Permit Number •See reverse side for instructions for completing this app! lion.f r�yib c ::rlualu,1,` f1 ?O6F- Personal information you provide may be used for secondary p y ry purposes(Privacy,Law.s.-15.04(1}{ri1 U Check if ren to prelcatlon State Plan Review Transaction Number I.APPLICATION INFORMATION —Please print all information Proper y Owner Name Propor Location Ur �e!c: Adel 3 r5 A/ ALtf Y. L-7 e r. S c4 T 7 ,N, R l< F Property let's Mailing Address Lot Number Block Number Y6/ / 0/4-L3 LcrtitlE. ,s City,State Zip Code Phone Number Subdivision Name or CSM,Number R4�iIk Z z s 3 7/, ( ) /1 A—Silt_i CI '4 S tyal ,./ R4 II. TYPE OF BUILDING: (check one) ovia9a OF: /) 0 0sown l_-d fro(le, aiee,v c U Public Parcel Tax Number 41 or 2 Family Dwelling-No.of bedrooms \ Oi V- O 7/(- (')6 c, ( Y- III. BUILDING USE: (if building type Is publi , eck 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: Sates I 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. L., Replacement 3. ❑ Replacement of 4. Reconnection of 5. ❑ Repair of an System Tank Only Existing Syste_mm) Existing System 9) ❑ A Sanitary Permit was previously issued. Permit Number '-- —D t ss�`ued .. V. TYPE OF INSTALLATION OR REGULATED ACTIVITY ❑Pump Chamber-Gravity I.G. ❑Terralift"' Nan Plumbing Sanitation System Privy Q Revision of Plumber ❑ Specify type, ❑Pit Privy ❑Vault Privy VI.ABSORPTION SYSTEM INFORMATION: For Reconnection,Plumber Transfer&TerrallftTM I.GALLONS PER DAY 2.AI sore.Area Renuired a.Adsorp,Area proposed 4,Loading Rate(gals/day/Wt.) 6,Pero,Rate(mlq gnctq''a,$ystem BIM(cn peel} 7.Final T rade elevation I (sq.ft.) `- Exlsuna(eq.A.) � - ,-- ^,_^ (feet) — VII. TANK INFORMATION Cepacityingatlons Total aof Prefab. Site Fiber. New Existing Gallons Tanks Manufacturer's Name Concrete CI"' Steal glass Plastic Tanks Tanks strutted Septic Tank >a 66 e2006 c ri‘N J 7� ' ❑ ❑ ❑ ❑ Lift Pump Tank/Siphon Chamber 6 N (c,Q C ❑ ❑ 0,_. ❑ ❑ VIII. RESPONSIBILITY STATEMENT { the TenaliRTM process; I,the undersigned,assume responsibility for 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: n :' SI Wu*-'- s: MP/MP:8 / THER ft Ovalness P ne Number: / • C.-7, Y e0/-A- (7ce PLUMBER'S APO sk et,oily,slate,zip odds �' l 7.36 _L)4.4. /.n �r eg6te - - IX. COUNTY USE ONLY /1 San Permit Foe cafe Issued ISSUI AG . - = y • � r Ps) Apprppved ❑Owner Given Initial ,A� C� J isapproved Adverse Determination ��// X. CONJ ITIONS OF APPROVAL! REAS NS FOR DISAPPROVAL: AS ste --n►e PQ`" u 1. _ • l _ t ' :� g- e- 3.4r- -- -7--..r . • _ •.L . ..r .`- -w 0� -`4 i 1 - ..--. ..ii .._.a • ' --P'''a ' 'lL ." .A.— _-4.k 941A4a1A rnm71