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Public Health MADISON &DANE COUNTY Janel Heinrich, MPH, MA, Director Healthy people and places Environmental Health Division 608 242-6515 Well&Septic 2701 International Lane,Suite 204 608 243-0330 Lic. Establishments Madison,WI 53704 608 242-6435 fax www.publichealthmdc.com Building Permit Review Application Applicant(owner or Authorized Agent) Phone:608-235- and Owner or not applicant) Matthew Tills,Applicant; Basil Tikoff and Sara Hotchkiss,Owners 6240 Address of Property Owner or 2517 Balden St.Madison,WI 53713,Owner/Subject property Authorized Agent: SW 1/4, SW 1/4, Section:27 Township:Town of Madison Location of Property: Subdivision:Forest Blk 3, Lot 6 Park, Parcel Number: 070927366565 Property Address: 2517 Belden St.Madison,WI 53713 EXISTING HOUSE AND PRIVATE ONSITE WASTEWATER TREATMENT SYSTEM(POWTS): Type of POWTS:(check all that apply): ® Septic Tank ❑ Aerobic Treatment Unit ❑ Seepage Bed ❑ Seepage Trench ❑ Seepage Pit(Drywell) ❑ Mound ❑ At Grade ❑ Inground Pressure ❑ Cesspool Other(explain):unknown seecane/field desinn Date of POWTS Installation(if known):unknown Owner at time of Installation:unknown Size of POWTS:Tank: gallons,Soil Absorption Area: Square Feet,Last Pumped: Age of Existing House:63 vrs years,Size of Existing House:1.270 Square Feet,Number of Bedrooms:3 TYPE OF PROPOSED CONSTRUCTION: ❑ New Structure ❑ Replacement Structure(Fire,Tornado,Flood,Mobile Home Replacement,etc.): ❑ Remodeling If remodeling,how many Sq.Ft.: Describe Remodeling:. ❑ Detached Accessory Structure(Specify:Garage,Pole Barn,Shed,etc.): Will there be plumbing?❑Yes❑No CO Addition If addition,what is the size of the addition:654 sq.ft.,Dimensions:24'x28' ,Type:ICF walls If addition,does the addition contain bedrooms:®Yes❑No if yes,how many:2 Total number of bedrooms after addition:3,If addition total number of people using structure/system after addition:3 Other: (POWTS sizing is based on 2 people per bedroom using 75 gallons of water per person per day.) PLOT PLAN: Provide a drawing of your property drawn to scale or adequately dimensioned showing lot lines,well(s),existing POWTS and POWTS replacement area(if known),all existing structure(s),proposed construction(dotted lines,or clearly labeled)and distances between above. :..r If a POWTS is found to be a cesspool or It'found discharging onto the surface of the ground or into ground water,surface water,or bedrock on the above property,this will be considered POWTS failure and the falling POWTS will be ordered corrected. Signature of owner or auttorized agent is required and Indicates the above information Is accurate to the best of your knowledge and Indicates the owner's permission-Is given to inspect the property for the purpose of this review. I • - oot Owner/Authorized Agent Dat1 e tow Allow at least two(2)weeks for review to be completed,after required information is received. e tow at rithq 64e, 11/04/14-Building Permit Review Applicallon.doc