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W NE COUNTY -OQ 1 of 103 DANE COUNTY
<br /> DEPARTMENT OF HUMAN SERVICES
<br /> SA. 'MARY PERMIT APPLICATION Environmental Health Section
<br /> •Attach :omplete plans for the system,on paper not less than 81/2 x 11 inches in size, 1202 Northport Drive,Madison,WI 53704-2088
<br /> nor me e than 8'/x 17 inches in size. Sanitary Permit Number
<br /> •See reverse side for instructions for completing this application. ', um
<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 Owner Name Property Location
<br /> A) 5W % '54 %, s 5 T 8 ,N, R .7 E
<br /> Property Owner's Mailing Address Lot Number Block Number
<br /> Co 12-7 Old 51.k>t'lkr_S I
<br /> City,State Zip Code Phone Number Subdivision Name or CSM Number
<br /> Mazorvvt,tt1:g. 5354-0 ( ) -13-77
<br /> ❑city
<br /> II. TYPE OF BUILDING: (check one) ❑village}OF:
<br /> 'Town Pegry
<br /> ❑ Public Parcel Tax Number
<br /> '1 or 2 Family Dwelling-No.of bedrooms 4 c:130-7-053-9 30 1-5
<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
<br /> IV. TYPE OF PERMIT: (Check only one box on line A.Check box on line B,if applicable) R
<br /> A) 1. ❑ New System • 2. ❑ Replacement 3. ❑ Replacement of 4. d Reconnection of 5. ❑ Repair of an
<br /> System Tank Only Existing System Existing System
<br /> B) If 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
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<br /> VI.ABSORPTION SYSTEM INFORMATION: For Reconnection,Plumber Transfer&Terraliftru
<br /> 1.GALLONS PER DAY 2.Absorp.Area Required 3.Absorp.Area Proposed 4.Loading Rate(gals/day/sq.tt.) 5.Pere.Rate(min./inch) 6.System Elevation(feet) 7.Final Grade Elevation
<br /> (sq.tt.) E>dsti (sq.ft.) (feet)
<br /> C;00 IC:00 I tO5 •Co — 96-96.01-c34.I)
<br /> VII. TANK INFORMATION capacity in gallons Total #of Prefab. Site Fiber-
<br /> New Existing Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic
<br /> Tanks Tanks stNcted
<br /> Septic Tank 16O Imo ila.4Zo ^^C-4 pc- 53. 00 ❑ ❑
<br /> " Lift Pump Tank/Siphon Chamber _ ❑ ❑ ❑ _ ❑ ❑
<br /> VIII. RESPONSIBILITY STATEMENT r❑the Terraliftt process;
<br /> I,the undersigned,assume responsibility for {`❑the installation of a privy or other non-plumbing sanitation system;
<br /> ❑the repair/reconnection of the POWTS or POWTS component(s);on the attached plans.
<br /> NAME:(pent) SIGNATURE:(no stamps) MP/MPRSW/OTHER# Business Phone Number.
<br /> 15syvi,cw W, h4L4-1- Nell c/ oe.-- Lt./ . 22011A- ( 83 t,8703
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<br /> PLUMBER'S ADDRESS:(street,city,state,zip code)
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<br /> IX. COUNTY USE ONLY t.!1 ,_... �,, I, DOES NOT-HOLD'
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<br /> �A roved ❑Owner Given Initial Sanitary-ermitFee-), 1-1—' i� 1■SSION.'' .— l&i:MIZTF= '' `A ' r
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<br /> P li < Cra'J rr7UCi`ION
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<br /> X. CONDITIONS OF APPROVAL/ REASON b, si • OVAL KO G DDI Al.,� -� �1 - w Li 2 3 �
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<br /> Dane County Environmental
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