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'.•: 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 /> and Owner(Owner or Authorized Agent) /74/1"7 �.y�7/J 6,/'f7 Phone: <br /> and OWner(if not applicant) Cr y` ( �/ <br /> Address of Property Owner or 6q / 9 e!�Q/42 <br /> Authorized Agent: <br /> Location of Property: <br /> Ne 1/4, s. 1/4, Section: 1 t Township:�j7� <br /> Subdivision: , Blk , Lot <br /> Parcel Number: C3"1"-- I q 3 $2-3j—.7 <br /> Property Address: 6 Rq Ai A /A-"e,r, <br /> EXISTING HOUSE AND PRIVATE ONSITE WASTEWATER TREATMENT SYSTEM(POWTS): <br /> Type of POWTS:(check all that apply): <br /> Septic Tank ❑ Aerobic Treatment Unit ❑ Seepage Bed <br /> ❑ Seepage Trench ❑ Seepage Pit(Drywell) X Mound <br /> ❑ At Grade ❑ Inground Pressure Cesspool <br /> Other(explain): P V7 486— 0 '2-Z .Dr✓Lt o 9-s"----(q (PG <br /> Date of POWTS Installation(if known): fi"( s--t9t b Owner at time of Installation: C.Weci7 7 <br /> Size of POWTS:Tank: I 6-� gallons,Soil Absorption Area: 37c Square Feet,Last Pumped: <br /> Age of Existing House: years,Size of Existing House: Square Feet,Number of Bedrooms: <br /> TYPE OF PROPOSED CONSTRUCTION: <br /> El 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 /> J . Addition <br /> *If addition,what is the size of the addition: sq.ft., Dimensions: ,Type: <br /> if addition,does the addition contain bedrooms:I1t .Yes❑No If yes,how many: L <br /> Total number of bedrooms after addition: i ,If addition total number of people using structure/system after addition: yQr,0/p <br /> i <br /> Other: <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 /> Sign- - • •wner uthorized agent is required and indicates the above information is accurate to the best of your knowledge <br /> a•. indi j .ner's permission is given to inspect the property for the purpose of this review. <br /> ��1 n .,,,.scav 65 ,1530/4e. //. 6-29 - 20/r <br /> -; - . A uthorized ''nt Date <br /> Allow at least two(2)weeks for review to be completed,after required information is received. � <br /> 06/29/15-Building Permit Review Application.doc 1 ���� c 4241(4- <br /> 464111Y 7 (4 / <br />