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..ink.Mir,. MMMIS II ■ -- '•- chy_gni6 111 l��L�l1.._u--Ly,--: i 1 LMl1L t,UUl1I II <br /> $ANIj R PERMIT APPLiCATIO �, i 1 ipEPARTMENT OF HUMAN SERVICES <br /> Environmental Health Section <br /> Attach com tans for the system,on paper not less tha 's� 11 ittd1 s il�&ize20O9 11202 Northport Drive,Madison,WI 53704-2088 <br /> "nor more Than x 17 inches in size. {{ 5anilary Permit Number <br /> See reverse side for instructions for completing this applicati n. L. . . ,... ..-- .._.,.-__-.._...E �O <br /> F colic 1-icaltth MDC <br /> 'ersonal information you provide may be used for secondary purpose lPriva�ati ,!r ,'.d4(1 f'(ri -- ❑Check if revision to previous application <br /> Stale Plan Review Transaction Number <br /> .APPLICATION INFORMATION — Please print all information <br /> Property Owner Name Property Location Q//L/"14 ,/z c I9L J . / lsi— Y. S ItiAV p T / ,N, R <br /> E <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 6x1/8 C-9 oc, .-ot AP . <br /> / <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> g2v,4'z4Ni4,4 wl .5-.._3.5-4 Q (6 )d'', 1-L 977 <br /> --r Ai ,V..3 4- <br /> II. TYPE OF BUILDING: `check one) ❑Coy <br /> 1 ) ❑Village OF: ,I41/9 L�MAAi`.€ <br /> ❑ Public ''Town <br /> Parcel Tax Number <br /> 'I 1 or 2 Family Dwelling—No.of bedrooms 3 09'6- .?2P/- 9,5-3 x?- 2 <br /> III. BUILDING USE: (if building type is public,check all that apply) 9 ❑ Office/Factory <br /> 1 ❑Apartment I Condo 5 ❑ Hotel 1 Motel 10 ❑ Outdoor Recreational Facility <br /> 2 ❑Assembly Hall a ❑ Medical Facility/Nursing Home 11 ❑ Restaurant/Bar/Dining <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 12 ❑ Service Station/Car Wash <br /> 4 ❑ Church I School 8 ❑ Mobile Home Park 13 ❑ Other: specify <br /> IV. TYPE OF PERMIT: (Check only one box on line A.Check box on line B, if appl cable) <br /> A) 1. ❑ New System 2. ❑ Replacement 3. ❑ Replacement of 4. Reconnection of 5. ❑ Repair of an <br /> System Tank Only Existing System Existing System <br /> B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued <br /> V. TYPE OF INSTALLATION OR REGULATED ACTIVITY <br /> ❑ Pump Chamber—Gravity I.G. ❑TerraiitP" Non Plumbing Sanitation System Privy <br /> ❑ Revision of Plumber ❑ Specify type ❑ Pit Privy ❑ Vault Privy <br /> VI.ABSORPTION SYSTEM INFORMATION: For Reconnection, Plumber Transfer&Terralift' <br /> 1.GALLONS PER DAY 2.Absorp.Area Required 3.Absorp.Area proposed 4.Loading Rate(gaisrdayrsq.lt.) 5.Pero.Rata(min./inch) 6.System Elevation(reel) 7.Final Grade Elevation <br /> (sq.R.) Existing(sq.n.) / (reel) <br /> 5612 9v� pv � 0 , S ,^//4 Q'Y- L /vim . J <br /> paci in gallons <br /> VII. TANK INFORMATION CaNew Existing Total it of Manufacturer's Name Prefab. Site Steel Fiber- Plastic <br /> Tanks Tanks Gallons Tanks Concrete strutted 0„9 <br /> Septic Tank /oov /12J° / 1./ /Xer✓bw1✓ VI ❑ ❑ ❑ ❑ <br /> Lin Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ ' <br /> VIII. RESPONSIBILITY STATEMENT r CI the Terralitttm process; <br /> I,the undersigned,assume responsibility for {l 0 the installation of a privy or other non-plumbing sanitation system; <br /> U the repair/reconnection of the POWTS or POVVTS component(s);on the attached plans. <br /> NAME:(pIlnl) SIGr TU :(no -m- ) MP/MPRSW I OTHER 0 Business Phone Number. <br /> C//'4'/ ' LoPc/Z �- b , ?? 0 6 - A 3-- fs.3 <br /> PLUMBERS ADDRESS:(street,city,slate,zip code) <br /> ";'6/ fA7,c if ft‘ (sire k zcry <br /> IX. COUNTY USE ONLY _ <br /> r ..roved ❑ Owner Given Initial Sanitary Permit Fee Dale sued ISSUING A4 -NAT stamps) <br /> ■ Adverse Determination i `�Q • Al,Dies •roved ` O ' / <br /> X.'CONDITIONS OF APP•OVAL! REASONS FO• DIS PPROVAL: <br /> /c,--e_ . <br /> ISA - A - • _ ■ _ <br /> .t. _ - L. • - f AA <br /> " <br /> 231-245-15 WW1 <br />