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%•�. '�• • Public Health MADISON St DANE COUNTY Janel Heinrich, MPH,MA, Director Healt y people and places Environmental Health Division 608 242-6515 Well&Septic 2701 international Lane,Suite 204 608 243-0330 tic. Establishments Madison,WI 53704 608 242-6435 fax www.publichealthmdc.com Building Permit Review Application q Applicant(Owner or Authorized Agent) j-- and Ownerptnotapplicenn BnG r--• d I/�f ea_ B/ L I Phone: , Address of Property Owner or !� p Authorized Agent: NO 3 - �7 7 r 8 gdJ v, /l 5350 1/4, 1/4, !Section: Township: Location of Property: Subdivision: , Blk , Lot Parcel Number. o 50&- f/ -i5o/ 7 Property Address: /UQ 3 M.07 P3 B 6.0):1l� V� • , , l / _5 EXISTING HOUSE AND PRIVATE ONSITE WASTEWATER(TREATMENT SYSTEM(POWTS): Type of POWTS:(check all that apply): Septic Tank ❑ Aerobic Treatment Unit ❑ Seepage Trench ❑ ❑ Mound Bed Seepage Pit(Drywall) ❑ Mound ❑ At Grade 0 Inground Pressure Other(explain): ❑ Cesspool Date of POWTS Installation(if known): Owner at time of Installation: .5-/ef/i _ Geis-2r Size of POWTS:Tank: gallons,Soil Absorption Area: Square Feet,Last Pumped: Age of Existing House: 4-L0 years,Size of Existing House:, ( 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. V Addition ): Will there be plumbing?❑Yes❑No *If addition,what Is the size of the addition: CDasiA sq.ft.,Dimensions: If addition,does the addition contain bedrooms:❑Yes*No If yes,how many: Type: Total number of bedrooms after addition: ,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. If a POWTS is found to be a cesspool or is 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 failing POWTS will be ordered corrected. Signature of owner or authorized 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 roe purpose P rtY for the p rpose of this review. Owner/Authorized Agent Date Allow at least two(2)weeks for review to be completed,after required information Is received. 08/18114-Buildieg Permit Review Appllcefion.doc