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Public Health <br /> MISON &DANE COUNTY Janet Heinrich,MPH,MA,Director <br /> Raab,peoPe a>'tcipieces Environmental Health Division 608 242-6515 Well&Septic <br /> 2701 International Lane,Suite 204 608 243-0330 Lid Establishments <br /> Madison,Wi 53704 608 242-6435 fax • <br /> www.publichealthmdc.cdrrt <br /> Building Permit Review Application <br /> AppNcant(Omer at Aulrerz.dAgent) Phone: <br /> and Owner pr not applicant) %.7'o Gl9644 G41e5.57°}C1j7;00¢Gam, _ • -.r <br /> Address of Property Owner or <br /> Asthor)zedAgent 7/65 Goy/-SPR4446 - 4)14- /2d. <br /> /.JW 1/4, Ai&I 114, Section: z,e) TownshiPia4A t 110 <br /> Location of Property: <br /> Subdivision: , Bik , Lot / eaosi /E/4 �. <br /> Parcel Number. 09 o8 - 2d 2. <br /> - 8540 -.3 <br /> Property Address: 7/6S 4040 .Srr3ft/duct dF'/e-C,1j 02.. W f \/i 1- <br /> EXISTING HOUSE AND PRIVATE ONSITE WASTEWATER TREATMENT SYSTEM(POWTS): <br /> Type of POWTS:(check all that apply): <br /> i�Septic Tank ❑ Aerobic Treatment Unit ❑. Seepage Bed <br /> ❑ Seepage Trench ❑ Seepage Pit(Drywell) 1 - 1 tbund <br /> O At Grade El Inground Pressure ❑ Cesspool <br /> Other(explain): <br /> Date of POWTS Installation(if known): 8-3-01 Owner at time of instalation: /144,4 V fVCP-44 <br /> Size of POWYS:Tank:/a gale gallons,Soil Absorption Area:/414 2.-Square Feet,Last Punjped: <br /> Age of Existing House: years,Size of Existing House: Square Feet,Number of Bedrooms: 'f <br /> TYPE OF PROPOSED CONSTRUCTION: • <br /> ❑ New Structure ❑ Replacement Structure(Are,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 /> (;r"Addflon <br /> *f addition,what Is the size of the addition: 1 220 sq.ft.,Dimensions: 27 x 33 ,Type:6kive/L Win j <br /> *f addition,does the addition contain bedrooms:Ill Yes❑No if yes,how many: 1.. <br /> Total number of bedrooms after addition: ,If addition total number of people using structure/system after addition: U <br /> Other:, <br /> (POWYS sizing Is based on 2 people per bedroom using 76 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 /> POINTS 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 falling POWTS will be ordered <br /> cotleoted. <br /> Sign tore of owner or authorized-ant is requ d and indicates the above Information is accurate to the best of your knowledge <br /> and I ,Icates the o..s permission is given to nspect the property for the purpose of this review. f ' 1� <br /> ofrA <br /> -•",, ,orize 14h Data <br /> Allow at least two(2) ks for review to be completed,after required Information Is received. <br /> 07H4115-eutldtrtg Permit ReviewApplIcagondoo <br /> • <br />