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<br /> iI
<br /> '� "Public Health
<br /> MADISON&DANE COUNTY. Janet.Hellukh•MPH,MA,Director:: 1
<br /> ttalthy peaple and pla(� i:nvirunmental Health Divlsian 608 242-6S i 5 Weil&'Septic
<br /> i 2701 International Lane,Suite 204 606 243-0330 Uc.Establishments
<br /> i - Madison,WI 33704
<br /> $(ie:24�-643�fax--
<br /> www.publkhealttimdCcotn
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<br /> Building Permit Review Application
<br /> AppNcanttoerreror! tAVe+�ti Siv.44,--" t�aO‘w — l4thricaw. a wrist i' a-ww_f
<br /> and Owner(snaeprecanq nb{, '� M'C: I PtKNle: s fZ` '�
<br /> Address of Propeny Owner or . n - 1
<br /> I = Address o 7 I3 lri+ �-t) gr1t+ o iJ1 t 7
<br /> f/4 N e 1/4, `Sallow Towns ( u,
<br /> Location of Property:
<br /> sic Lot
<br /> Parcel Number. 6b O D'�O to .« 071 _
<br /> Property Address: .iti
<br /> - dam#--r / It-.>� j c,?- S3s--
<br /> EXISTING HOUSE AND PRIVATE ONSITE WASTEWATER TREATMENT SYSTEM(POWTS); fEE
<br /> Type of POWTS:(check all that apply) 1
<br /> �( Septic Tanli ❑ laTreatmant Unit
<br /> El Seepage Bed '
<br /> ❑ Se apago Trench ❑ _
<br /> ?q N ) ❑ Mound
<br /> 1 =At Grade El.._inground••,^^'tire ❑ Cesspool
<br /> Other(e�cplain). _
<br /> Date of POWTS irrstalatiwi Of known) c owner at time of.tnstt iori.
<br /> Sim of POWTS:Tanis l aoo = . est pumped; }^'rc . .
<br /> galoo, Soll Absotptbn Ar t jla Square Feet,.t ask oBe
<br /> Age of E dsfhg House 'l- �(
<br /> y yea's,Size of P,dsf>r>g House; / square r-set..Nix nber of eedrooms:, 3
<br /> =TYPE OF PROPOSED CONSTRUCTION:
<br /> ❑ New SQttdure [] :Replacement Structure(Fire,Tornado,flood,Mobile Home Replacement.eta.);
<br /> t Remodeling if rem)deing,how many 8q.-Pt,: Descstbe Remodeling.
<br /> I El Detached Accessory Straotare($peclfy'Garage,Pole tern,shed,etc.) _ WIi there be
<br /> 3 _ t7 Ayes❑Ni= ao
<br /> �( Addition ,r
<br /> if addition what is tt esize of the addition: :�r4/ *I!ft.,aimenelons: I 'x QB -�_f3�'o,P -Jlj�yfi /�"
<br /> 'If addition,does the addition contain bed:poltrs;) (Yes❑No if yes,flow merry I - ,
<br /> if Total number of bedrooms of beraddgton:_, _,if addion total manlier of people using_ slruclure/ey after adder y2
<br /> Other 7 ,tisr'�,�. 6rddorm .- h I/w4r ;-o foe 4.Q.✓ A f4f. .'os/ , t
<br /> 4dr'!�. be- User .G y✓
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<br /> (POWIS.sizing is based on 2 people per.bedroom using 75 gaol*of water Per peraoit PerdaY.)
<br /> PLOT PLAN
<br /> Provide a drawing of your property drawn to scale or a deglytlinerrsigned•showhtg bt qha,yfei(s),existing POWTS and
<br /> POWTS replacement area(If known),at ebucture(s),p oposed,consbudton(dotted fines,or dearly 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.falling POW S wilt be ordered
<br /> corrected.
<br /> Sign a of owner or authorized agent Is requked and indicates the above information`Is accurate to t e best of yWx knowledge
<br /> and I, !cal: •s owner's permission is given to Inspect the Property fa the purpose of ibis review.>
<br /> f� „ja )-ao
<br /> rLAuthortzed
<br /> Agent pa e { v
<br /> Allow at least two(2)weeks for review to be completed,ai r requi ed information is received.
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