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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(Omer
<br /> (frnot rAuuwrizedAgent) [1/iJ G / fe Phone: -
<br /> and Owner(ff not applicant) /fl��4 S r7 ,/Al/ .2
<br /> Address d Property Owner or ��8 ,4-& 7RIU Et / r , , r ���7_/
<br /> Authorized Agent: � Q�Y"�'^d'k (w 7 y
<br /> l�1
<br /> `N A/1/4, A55. 1/4, Section: 19 Township:
<br /> Location of Property: /
<br /> Subdivision: , Bik , Lot ,
<br /> Parcel Number. 0 O Z/e25 JA .. lg q — Bub -- 3
<br /> Property Address: C E
<br /> EXISTING HOUSE AND PRIVATE ONSITE WASTEWATER TREATMENT SYSTEM(POWTS):
<br /> Type of POWTS:(check all that apply):
<br /> Z. Septic Tank ❑ Aerobic Treatment Unit ❑ 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): q em4, Owner at time of Installation: EA l9Jh /110'Nsete
<br /> Size of POWTS:Tank: /OdO gallons,Soil Absorption Area: - Square Feet,Last Pumped: 3
<br /> Age of Existing House: years,Size of Existing House: Square Feet,Number of Bedrooms:
<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: .51 Z. 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: a ,If addition total number of people using structure/system after addition: a .
<br /> other. �AWYI7 4i 641i f NA< go--ozn- I'/Ii FJY4 p 6--7- I q?c, 1
<br /> 1154W A 3-- S69,20o" Hoc f.rE. IiWfit 114" A,P,o,2pj q_Z,y vac
<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 dearly 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 /> S' • re of owner or authorized agent is required and indicates the above information is accurate to the best of your knowledge
<br /> and indi : es the owner's permission is gi en to inspect the property for the purpose of this review.
<br /> • • b/073//c
<br /> Owner/Authori -•Agent Date
<br /> Allow at least two(2)weeks for review to be completed,=fter required Information is received.
<br /> WO 081(-7.
<br /> 06/23/15-Building Permit Review Application.doc Jei !'�/�®(Al(
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