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DANE COUNTY DANE COUNTY <br /> SA DEPARTMENT OF HUMAN SERVICES <br /> I�,�TARY PERMIT APPLICATION <br /> Environmental Health Section <br /> •Attact}complete plans for the system,on paper not less than 8%x 11 inches in size, 1202 Northport Drive,Madison,WI 53704-2088 <br /> nor more than 8%x 17 inches in size. Sanitary Permit Number <br /> •See rtiverse side for instructions for completing this application. <br /> Personal information you provide may be used for secondary purposes[Privacy,Law,s. 15.04(1)(m)]. ❑Check if revision to previous application <br /> State Plan Review Transaction Number <br /> I.APPLICATION INFORMATION — Please print all information <br /> Property Owngr Name,C A A i 1 //.✓ Property Location ' <br /> /,;J� /1 / /. /., S T ,N, R E <br /> Property Owner's Mailing Address / Lot Number Block Number <br /> 3 5 CY De,e-; Ei.thi 4 a <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number , <br /> 1C•4 1L,ti/Gtr was. 5.3 53/ ( : .7G 7/143 <br /> D City <br /> II. TYPE OF BUILDING: (check one) ❑village).OF: <br /> ❑ Public 0 Town <br /> Parcel Tax APor 2 Family Dwelling—No. of bedrooms <br /> III. BUILDING USE: (if building type is public,check all that apply) 9 ❑ 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 140M0- <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. ei 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. ❑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&TerraliftTu <br /> 1.GALLONS PER DAY 2.Absorp.Area Required 3.Absorp.Area Proposed 4.Loading Rate(gals/day/sq.ft.) 5.Perc.Rate(min./inch) 6.System Elevation(feet) 7.Final Grade Elevation <br /> (sq.ft.) Existing(sq.ft.) (feet) <br /> Capacity in gallons Site <br /> VII. TANK INFORMATION New Existing Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic <br /> Tanks Tanks Gallons Tanks Concrete strutted glass <br /> Septic Tank ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber.... ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT / (❑the TerraliftTM process; <br /> I,the undersigned,assume responsibility or (l❑the installation of a privy or other non-plumbing sanitation system; <br /> ❑the re.-it/re,•nnection of the POWTS or POWTS component(s);on the attached plans. <br /> NAME:(print) L SIG . U- :(no stamps) / I MP/MPRSW/OTHER# Bu Phone Number. <br /> „C�.nn;3 fro)-11e-ll� e.r - 7 00:77, P, I �I4`� Jsiness <br /> ad 574 • S'(' <br /> PLUMBER'S ADDRESS:(street,city,state,zip code) <br /> 382 y,/ �/`/'"'�,1,// Cn e_ Gravt, IL). ,,S-35-Z7 <br /> IX. COUNTY USE ONLY <br /> U Approved U Owner Given Initial Sanitary Permit Fee Date Issued ISSUING AGENT SIGNATURE(no stamps) <br /> ❑ Disapproved Adverse Determination <br /> X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: <br /> 231-248.15(4/01) <br />