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<br /> '••.' Public Health
<br /> MADISON & DANE COUNTY Janel Heinrich, MPH, MA, Director
<br /> Healthy people and places Environmental Health Division 608 242-6515 Well&Septic
<br /> 2701 International Lane,Suite 204 608 243-0330 Lic. Establishments
<br /> Madison,WI 53704 608 242-6435 fax
<br /> www.publichealthmdc.com
<br /> Building Permit Review Application
<br /> Applicant(Owner or Authorized Agent) R 0 ` �' °
<br /> and Owner(if not applicant) 06 r tat / d ,KS ,_clek.„A 0,,,, ,,k PhoneCgp 94311 S y SS `-
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<br /> Address of Property ert Owner or Q
<br /> Authorized Agent: O°I J ROY)VI/C I.-A VI P S (i,"t k io�' 2 VS ' _
<br /> a
<br /> A) 0 1/4, N to 1/4, pd Section: Township: KtS a HS l w s
<br /> Location of Property: P a Cf
<br /> Subdivision: , Blk , Lot
<br /> Parcel Number: 1
<br /> Property Address: (91,65--- CRmelv,,f 1_a,1( / l71©., L � "-o.ry / 2,(,y
<br /> EXISTING HOUSE AND PRIVATE ONSITE WASTEWATER TREATMENT SYSTEM(POWTS): Q
<br /> Type of POWTS:(check all that apply):
<br /> Septic Tank ❑ Aerobic Treatment Unit TA Seepage Bed
<br /> ❑ Seepage Trench ❑ Seepage Pit(Drywell) ❑ Mound
<br /> ❑ At Grade ❑ Inground Pressure ❑ Cesspool
<br /> Other(explain):
<br /> Date of POWTS Installation(if known): /51'20—7 b Owner at time of Installation: P°b6 : ��"`�Ia~
<br /> Size of POWTS:Tank: /649°c� gallons,Soil Absorption Area: 112(26 -Square Feet, Last Pumped:
<br /> Age of Existing House: 29 years,Size of Existing House: /660 Square Feet, Number of Bedrooms: 3
<br /> TYPE OF PROPOSED CONSTRUCTION:
<br /> ❑ New Structure ❑ Replacement Structure(Fire,Tornado, Flood, Mobile Home Replacement,etc.):
<br /> ❑ Remodeling If remodeling, how many Sq. Ft.: Describe Remodeling: .
<br /> ❑ Detached Accessory Structure(Specify:Garage,Pole Barn,Shed,etc.): Will there be plumbing?❑Yes❑ No
<br /> V4 Addition 57d
<br /> *If addition,what is the size of the addition: sq.ft., Dimensions: ,Type:
<br /> *If addition,does the addition contain bedrooms: ❑Yes 51 No If yes,how many:
<br /> Total number of bedrooms after additions:'" 3 , If addition(total number of people using structure/system after addition: .
<br /> Other: 4PP(? WV �qy /fi I r fi '� 2M--- -(--- f? 2 ✓V'C�
<br /> (POWTS sizing is based on 2 people per bedroom using 75 gallons of water per person per day.)
<br /> PLOT PLAN:
<br /> Provide a drawing of your property drawn to scale or adequately dimensioned showing lot lines,well(s),existing POWTS and
<br /> POWTS replacement area(if known),all existing structure(s),proposed construction(dotted lines,or clearly labeled)and distances
<br /> between above.
<br /> If a POWTS is found to be a cesspool or is found discharging onto the surface of the ground or into ground water,surface
<br /> water,or bedrock on the above property,this will be considered POWTS failure and the failing POWTS will be ordered
<br /> corrected.
<br /> Signature of owner or authorized agent is required and indicates the above information is accurate to the best of your knowledge
<br /> an icates the o er's permission is given to inspect the property for the purpose of this review.
<br /> evvvt_ -3�� g r c, S a Y- 9- /5
<br /> Owner/Authorized Agent _e fa-r(Sc I oc j c ms h , e o Yv\ Date
<br /> Allow at least two(2)weeks for review to be completed,after required information is received.
<br /> 04/09/15-Building Permit Review Application.doc
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