DCPZP-2008-00916 - Laserfiche WebLink

Home Browse Search

608-831-8107 NEINHOLZ EXCAVATING 107 P02 DEC 04 '08 13:32 vriarms.. *Air sir vum I I .., .,,..,... . 'SANI'TARY PERMIT APPLICATION ' DEPARTMENT OF HUMAN SERVICES Environmental Health Section •Attach complete plans for the system,on paper not less than 81A x 11 inches in size, 1202 Northport Drive,Madison,WI 537042088 nor more than 8%x 17 inches in size. Sanitary Permit Number •See reverse side for instructions for completing this application. Personal information you provide may be used for secondary purposes Privacy,Law,s.15.04(1)(m)I. ❑Check if revision to previous application State Plan Review Transaction Number I.APPLICATION INFORMATION–Please print all information Property Owner Name Property Location hiltlUtm k NtanCy Btsnvrrtr NW Y. SW V.. S 6 T 6, .N. R IC E Property Owner's Mailing Address Lot Number Block Number to2oS R+cf ,N,ocat Ave. 1 City,State Zip Code Phone Number Subdivision Name or CSM Number (vlonona, WI _ S'S?ib ( ) C$M t2116 II. TYPE OF BUILDING: (check one) oY oF: Dunn ❑Public cel - Parcel Tax Number 141 or 2 Family Dwelling-No.of be Clio 10—0105 —i3f.z.e•-0 III. BUILDING USE: (if building type is public,check Ng 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. lir Reconnection of 5. ❑ Repair of an 1 System Tank Only Existing System Existi g System B) IJ A Sanitary Permit was previously issued. Permit Number 41977 I Date Issued f a/dZ _ V.TYPE OF INSTALLATION OR REGULATED ACTIVITY ❑ Pump Chamber-Gravity I.G. ❑TerralifTM Non Plumbing Sanitation System Privy ❑Revision of Plumber ❑Specify type ❑Pit Privy ❑Vault Privy VI.ABSORPTION SYSTEM INFORMATION: For Reconnection,Plumber Transfer&TerralifTM 1.GALLONS PER DAY 2.Absorp.Area t ,•.Area 4.Loading Rate(galsldaytsq.A) 5.Pere.Rate(mkt/inch) 8.System Elevation(teet) 7.Final Grade Elevation (sqA) 4 3i'_i.i• •.tL) Cam. \ ( ) g1 0 1 '�° tt� - 4 ',-/.0 92.5- VII. TANK INFORMATION cti, „ga. Total s of Pte. $i1e Fiber- " '' Gallons Tanks Manufacturer's Name Concrete strutted Steel glass Plastic Tanks Tanks Septic Tank — tLVL> MOO I pal moray tef ❑ ❑ ❑ ❑ Lilt Pump Tank/Siphon Chamber.... ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBIUTY STATEMENT O the TerratifTM process; _a i,the undersigned,assume responsibility sponsibFlity for O real ctnectiany of POWT PW TS comport (s);on the attached plans. NAME:(print) SIGNATURE:(no stamps) r OTHER s Busked'Phone Number. 7+Mdrew W �1►-ir1�0i2 � _ W'ry 22O 5 I 831-3103 PLUMBER'S ADDRESS:(sued,dry,Mete,zip code) (co)3 CT-i-I K Waunakee, WI 5 7 IX.COUNTY USE ONLY Given —444 �O Odvsmn San"Permit F �3 Data broad/ � ,,i , O Are D.ternation P-13/6tij `Air ./� O L• • X.CONDTONS OF APPROVAL/REASONS FOR DISAPPROVAL: -e) otivicwsc 7"CkST/1/4-6--qi)Ve 5t6 A (viNv't 14t09r criL0 kkrsc 231-245.15(4/01)