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..•.. <br /> 'or.' 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.corn <br /> Building Permit Review Application <br /> Applicant(Owner or Authorized Agent) Sunburst Land LLC <br /> and Owner(it not applicant) Phone: <br /> Address of Property Owner or 1003 CTH"PB" <br /> Authorized Agent: <br /> SE 1/4, NW 1/4, Section:20 Township:Montrose <br /> Location of Property: <br /> Subdivision: , Blk , Lot <br /> Parcel Number: 0508-152-9501-7 <br /> Property Address: 1003 <br /> EXISTING HOUSE AND PRIVATE ONSITE WASTEWATER TREATMENT SYSTEM(POWTS): <br /> Type of POWTS:(check all that apply): <br /> ® Septic Tank ❑ Aerobic Treatment Unit <br /> ® 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): Owner at time of Installation: <br /> Size of POWTS:Tank: 1000 gallons,Soil Absorption Area: 1200+/- Square Feet,Last Pumped: <br /> Age of Existing House: years,Size of Existing House: 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 /> ® Addition <br /> *If addition,what Is the size of the addition: sq,ft.,Dimensions: ,Type: <br /> if addition,does the addition contain bedrooms: ❑Yes❑ No If yes, how many: , <br /> Total number of bedrooms after addition: , If addition total number of people using structure/system after addition: <br /> Other:No obiection to addition tohouse as shown on site plan,Existing septic system is compliant with existing code and a futyre <br /> replacement area has been delineated. <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 o,owner or authorized agent is required and indicates the above information is accurate to the best of your knowledge <br /> and;''ic:l s�i e owner's permission is given to inspect the property for the purpose of this review. <br /> `l-, r C 114 G.T^'— -*/.4.A(��i/j2/4-VV. 4( 22 --.2-0(S—' <br /> Owner/Authorized Agent Date <br /> Allow at least two(2)weeks for review to be completed,after required information is received. <br /> 04/22/15-Building Permit Review Appllcation.doc <br />