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- t-f 3(05(2 U DANE NTY 1)8*-'b C a,+0 (L# -° p DANE COUNTY DEPARTMENT OF HUMAN SERVICES SANITARY PERMIT APPLICAT101� - J/ Environmental Health Section •Attach complete plans for the system, on paper not less than < 11 inches in size, 1202 Northport Drive,Madison,WI 53704-2088 nor more than 81/2 x 17 inches in size. AUG — 6 2008 Sanitary Permit Number • See reverse side for instructions for completing this applicat . L�epvyv S 1 a (�) 7050 Personal information you provide may be used for secondary purposes[PraecYUblle tiefl th M� � Li Check if revision to previous application 1' ntal Health Plan Review Transaction Number I. APPLICATION INFORMATION — Please print a41 ifl AW.4iW'' ' -PAIN i6 PUcrf.I 41 (676° Property Owner Name Property Location 001.)0. A E ss e, N W % 5 ' Y., s ea -r .5 ,N, R 1 E Property Owner's Mailing Address Lot Number Block Number y36 s-1-t-4 Ia City,State Zip Code Phone Number Subdivision Name or CSM Number 'eroto a , w ; 535g3 (668 )831- 443P . li City II. TYPE OF BUILDING: (check one) ❑Village}OF: Qe,i...-.r0se__ 41 Town a Public Parcel Tax Number g�38 _� IA 1 or 2 Family Dwelling—No. of bedroo 05501 - oat.;- . III. BUILDING USE: (if building type is public, c 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: Sales/Repairs 12 ❑ Service Station/Car Wash 4 ❑ Church/School 8 ❑ Mobile Home Park 13 LI 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. 'Z' Reconnection of 5. ❑ Repair of an System Tank Only r Existing System Existing CSyystem B) \A Sanitary Permit was previously issued. Permit Number 2/t0 3-e2 t Date Issued <2 l(7"-9 7" V. TYPE OF INSTALLATION OR REGULATED ACTIVITY ',PA H( qt -o 93 ❑ Pump Chamber—Gravity I.G. ❑TerraliftTM' Non Plumbing Sanitation System Privy ❑ Revision of Plumber ❑ Specify type ❑ Pit Privy ❑ Vault Privy VI. ABSORPTION SYSTEM INFORMATION: For Reconnection, Plumber Transfer&Terraliftn" 1.GALLONS PER DAY 2.Absorp.Area Required I3�orp.Area Proposed 4.Loading Rate(gals/day/sq.ft.) 5.Perc.Rate(min./inch) 6.System Elevation(feet) 7.Final Grade Elevation (sq.ft.) — (sq.ft.) (-6 0 31 S 315 e 5 Nfl VII. TANK INFORMATION Capacity in gallons Prefab. Site Fiber- New Existing Total #of Manufacturer's Name Concrete Con- Steel glass Plastic Tanks Tanks Gallons Tanks strutted Septic Tank 050 050 1 C.*eS--1 ® ❑ ❑ ❑ ❑ Lift Pump Tank/Siphon Chamber.... — 150 _ '7 SO / f I ® LI ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT r 0 the TerraliftTM process; I,the undersigned,assume responsibility for {`0 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:(print) SIGNATURE:(no sta ps) MP/MPRSW/OTHER# Business Phone Number: T1�.0-0N/ JYe`\t- n��=+w� elite' �--1 S a 5 61DR 41c-74i b b PLUMBER'S ADDRESS:(sCreet,city,state,zip code) �/ 1 ' ` 5,3573 S0 1 COrs4N..",ewce PKWY( \)eN`0,.. tl` L) IX. COUNTY USE ONLY ) Sanitary Permit Fee Date Issued ISSU G ENT GNATURE(no st ps) Approved Li Owner Given Initial (�'�j '❑ Disapproved Adverse Determination 1 203 - 8-7_08 it i 744h-7--- X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: -4 S gor ,6J 7 f, ('IVA-g-AFA(i tailf\/ --) RFt9 w(c To El(cs(r-trc_ w4 'A-t-41-Z-64 l q iYr