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608-831-81D7 MEINHOLZ EXCAVATING 974 PD2 AUG D4 'D8 1 :22 <br /> --w! 1:C ( v((--,' 4a •-Th <br /> CK <br /> "VANE COUNTY „* '133 D . L' [tt: w [7—; '� DANE COUNTY <br /> SANITARY PERMIT APPLICATIO DEPARTMENT OF HUMAN SERVICES <br /> Environmental Health Section <br /> •Attach complete plans for the system,on paper not less tha (11 ii es Z&e2OO8 1202 Northport Drive,Madison,WI 53704-2088 <br /> nor more than 8'/x 17 inches in size. Sanitary Permit Number <br /> •See reverse side for instructions for completing this application. i <br /> Public Health MDC 16`T <br /> Personal information you provide may be used for secondary purpos,s(Priv t>rG(ytrn4f fiki Mit1t}} ❑Check if revision to previ us application <br /> State Plan Review Transaction Number <br /> I.APPLICATION INFORMATION-Please print all information <br /> Property Owner Name Property Location <br /> VS1\llt4tM A Le �r y I eS!'ot./ NE % NW 'v4, s 23 T ,N, R IC' E <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 1130 Arita, C-t , UoVt 5 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> ModiWI W I 55113 ( ) <br /> U city <br /> H. TYPE OF BUILDING: (check one) U <br /> lad t}OF: Dijon <br /> ❑Public Parcel Tax Number <br /> Gil'1 or 2 Family Dwelling—No.of bedrooms cfo i O -232-SI LI O'7. <br /> III. BUILDING USE: (If building type is public,check all that apply) g ❑Office/Factory <br /> 1 ❑Apartment/Condo 5 ❑Hotel/Motel 10 ❑Outdoor Recreational Facility <br /> 2 ❑Assembly Hall 6 ❑Medical Facility/Nursing Home 11 ❑ Restaurant/Bar/Dining <br /> 3 ❑ Campground 7 ❑Merchandise: Sales/Repairs 12 ❑ Service Station/Car Wash <br /> 4 ❑Church/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 applicable) <br /> A) 1. ❑ New System 2. ❑ Replacement 3. ❑ Replacement of 4. ( Reconnection of 5. ❑ Repair of an <br /> System Tank Only Existing Q Existing System Exi ting System <br /> B) a A Sanitary Permit was previously issued. Permit Number 4566 Date Issued //)7-' 6 <br /> V.TYPE OF INSTALLATION OR REGULATED ACTIVITY <br /> ❑Pump Chamber—Gravity I.G. ❑TerraliftTM Non Plumbing Sanitation System Privy <br /> ❑Revision of Plumber ❑ Specify type ❑Pit Privy ❑Vault Privy <br /> VI.ABSORPTION SYSTEM INFORMATION: For Reconnection,Plumber Transfer 8 TerraliftT"' <br /> 1.GALLONS PER DAY 2.Absorp.Area ul .Area Pr000sed 4.Loading Rate(galslday/sq.rl.) 5.Pere.Rate(min./inch) 6.System Elevation(feet) 7.Final Grade Elevation <br /> MA) .14) (feet) <br /> W O O grAZCO :'ck` ►rPr 3 94,•2 <br /> VII. TANK INFORMATION c E,r, 'a Gallons Tanks <br /> Concrete Site glass <br /> Manufacturer's Name Con- Steel Plastic <br /> New Tanks Tanks stNcted <br /> Septic Tank — Za00 Zora0 2 ® ❑ ❑ ❑ ❑ <br /> Lift Pump_Tank/Siphon Chamber.... — _ — el- ❑ ❑ _ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT r O the TerraliftTm process; <br /> I,the undersigned,assume responsibility for l 0 the installation of a privy or other non-plumbing sanitation system; <br /> 0 the repair/reconnection of the POINTS or POWTS component(s);on the attached plans. <br /> NAME:(print) SIGNATURE:(no stamps) ,MPRSW/OTHER N Business Phone Number: <br /> Ana Kim W- M_,trl'�'L ✓tt.-t-- U-1.-1^---{� J 22ot65 °v3 I.5103 <br /> PLUMBER'S ADDRESS:(street.city,state,zip code) <br /> P!1 3 en+ K t t arcu,Wt `.597 <br /> IX. COUNTY USE ONLY <br /> f:Irpproved U Owner Given Initial Sanitary Permit F Date t sued IS-, ./,_ `it r E(no stamps) <br /> A U Disapproved Adverse Determination +"l-'b 3 9/�� dee'AIVO. '-' p.s-4 <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> v - Y crovo tctmV C -i etr., 5sr-t-ic t(.. 9 1 14 4 <br /> /\ N 43-1. - cirLc . <br /> 231-248.15(41011 <br />