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DINE COUNTY -03 101 I03 DANE COUNTY SA. 'MARY PERMIT APPLICATION DEPARTMENT OF HUMAN SERVICES Environmental Health Section •Attach :omplete plans for the system, on paper not less than 8%x 11 inches in size, 1202 Northport Drive,Madison,WI 53704-2088 nor me e than 8'/:x 17 inches in size. Sanitary Permit Number •See reverse side for instructions for completing this application. '7 Q Personal information you provide may be used for secondary purposes(Privacy,Law,s. 15.04(1)(m)]. 0 Check if revision to previous application State Plan Review Transaction Number I.APPLICATION INFORMATION - Please print all information Property Owner Name Property Location Al S Stn/ y. SW %, S S T 8 ,N, R .7 E Property Owner's Mailing Address Lot Number Block Number to 12'7 Old ScxtUrS I City,State Zip Code Phone Number Subdivision Name or CSM Number MAZ-Cma as 535G-0 ( ) '1377 'U city II. TYPE OF BUILDING: (check one) ❑village}OF: GYTown ❑Public Parcel Tax Number Er1 or 2 Family Dwelling-No.of bedrooms ciy_rl_053-93o 1-5 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) R A) 1. ❑-New System • 2. ❑ Replacement 3. ❑ Replacement of 4. d Reconnection of 5. ❑ Repair of an System Tank Only Existing System Existing System B) El A Sanitary Permit was previously issued. Permit Number Date Issued 1 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&Terralift"" 1.GALLONS PER DAY 2.Absorp.Area Required 3.Absorp.Area Proposed 4.Leading Rate(gals/day/sq.tl.) 5.Pere.Rate(min./inch) 6.System Elevation(feet) 7.Final Grade Elevation (sq.1L) Existing(sq.ft.) (feet)— (e;00 4 1+ 1 OO 5 • o — . VII. TANK INFORMATION capacityingalions Total #df Prefab. Site Fiber- New Existing Gallons Tanks Manufacturer's Name Concrete stCnrn d Steel glass Plastic • Tanks Tanks Septic Tank k€o ISao MC-13 DC Iii- ❑ ❑ ❑ ❑ , Lift Pump Tank/Siphon Chamber.... - ❑ ❑ - ❑ ❑ - ❑ VIII. RESPONSIBILITY STATEMENT f 0 the Terralift A process; I,the undersigned,assume responsibility for l 0 the installation of a privy or other non-plumbing sanitation system; 0 the repair/reconnection of the POWTS or POWTS component(s);on the attached plans. NAME:(print) SIGNATURE:(no stamps) MP/MPRSW/OTHER# Business Phone Number flu,,, IN, iuc, Akte32 LAy— (4.7 , l 2.2 o t l/C ( 83 t,8103 PLUMBER'S ADDRESS:(street,city,state,zip code) 22 c.2.1.4 . w -1 WV G.�Gow-2S �If ( i i:.Af'IQVAi r eNmO CviL�'�-��- ' ...l.'' ��-�w,r.w .L HEALii-;DOES NOT HOLD IT�i IX. COUNTY USE ONLY .'/+[�+_ O ANY; AN DEFECTS IN PI a.Ns Sanitary•ermitFee'‘ �HLAR OMISSION.1'e • OR Is (jl , GENrsl A ...• ;::.i Approved 0 Owner Given Initial ;; C Ot�S� 7UGTION I. 1 e F t�// ❑Disapproved Adverse Determination 10 iii 0,,�.41 I . I AiL � ' - _ li_LTb umazataisrQ_4'.ta► ilraiaa ,wse•� �•_____ally X..CONDITIONS OF PPR VAL/ REASON,$, � : I g ROVAI s OR ADDI fl VE: X_ r,,- „ (' �►_o tpitpKING THIS MAY 2 3 2007 �r-C(,wt-"- Pi r • //L a t — a�.allf #. A TN. . .e.,/ ■ - Dane County Environmental