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<br /> '�' �'' Public Health
<br /> MADISON &DANE COUNTY Janet 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 AuthodzedAgenlo) ��_, Phone:
<br /> and Owner(ir not applcant) AQco►4 q��(4,s �o$-219-o/qo
<br /> Address of Property Owner or
<br /> Authorized Agent: 'tOD Utter IA. Qr DA:4'GsF 0.1- 5.3<-3 2_
<br /> 51A) 1/4, S V. 1/4, Section: /4 Township: 7
<br /> Location of Property:
<br /> Subdivision: , Blk Lot
<br /> Parcel Number: 63°-7 —A'& 600 —0
<br /> Property Address: ?)`(2. sort.i VaLy R,4 6( tts 53S-l5-
<br /> EXISTING HOUSE AND PRIVATE ONSITE WASTEWATER TREATMENT SYSTEM(POWTS):
<br /> Type of POWTS:(check all that apply): •
<br /> Septic Tank ❑ Aerobic Treatment Unit E' Seepage Bed
<br /> ❑ Seepage Trench ❑ Seepage Pit(Drywall) ❑ Mound •
<br /> ❑ At Grade ❑ inground Pressure ❑ Cesspool
<br /> Other(explain): ''nn
<br /> Date of POWTS Installation(if known): Il i/O!I977 Owner at time of Installation:Do,talrX 14.,,,i r tJ
<br /> Size of POWTS:Tank:/0004 soo gallons,Soil Absorption Area:85"0 Square Feet,Last Pumped:
<br /> Age of Existing House: 82, years,Size of Existing House: 8'70 Square Feet,Number of Bedrooms: 2.
<br /> TYPE OF PROPOSED CONSTRUCTION:
<br /> ❑ New Structure 0 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:1t 61'0 I sq.ft., Dimensions: 2) 30 Type:B-4 mkt i�,
<br /> *If addition,does the addition contain bedrooms:Pt Yes❑No If yes,how many: -5- I ,
<br /> Total number of bedrooms after addition: 3 ,If addition total number of people using structure/system after addition: 3 .
<br /> Other: 27th I Isd VL— , ,�-rtm... , Atlw S tCo.tir�. awe- (I/ 2SN1S4)
<br /> (POWYS 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 • •• er or authorized agent is required and Indicates the above Information is accurate to the best of your knowledge
<br /> and I •c- -- ' e owner's permission is given to inspect the property for the purpose of this review.
<br /> 1L y/22-//S-
<br /> O er/r uthorized Agent Date
<br /> Allow at least two(2)weeks for review to be completed,after required Information is received.
<br /> 08/18/14-Building Permit Review Appllcagon.doc
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