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<br /> ••• • P • lic Health
<br /> ' P i ON Et DANE COUNTY Janet Heinrich, MPH,MA, Director
<br /> Healthy people and/Acts
<br /> •. ... , (0..ftwielatized Aeon°
<br /> I Environmental Health Division 608 242-6515 Well&Septic
<br /> 2701 International Lane,Suite 204 608 243-0330 lic.Establishments
<br /> Madison,WI 53704
<br /> Building Permit Review Application 608 242-6435 fax
<br /> www.publicheatthmdc.com
<br /> [Phone:
<br /> and tab gnat applaud) ...7.01.404/5Fa /4145...SirICW•00 4.--,. •..
<br /> .,RI a property Owner or
<br /> A • .Agent:
<br /> i -7/46- e-oz",--Sete/4.,6.4-,,w4,4,) ogp
<br /> Ajw 114, m 64/ 1/4, —
<br /> Section: =,g, Township: )44A.;
<br /> 1—11 of Property: -----
<br /> Subdivision: , Bik , Lot / 4,,Si AC./C• -4e—
<br /> Pa • umber:
<br /> Pro,. y Addres$: -7/4.5 4...6.0/•--5,410,44-14:&ooreVZSC..4) .02.4. . LC)Q.E.
<br /> . : NG HOUSE AND PRIVATE ONSITE WASTEWATER TREATMENT SYSTEM(POWTS):
<br /> ;
<br /> • . POWTS:(check all that apply):
<br /> 0 Seepage Bed
<br /> • 0 Seepage Pit PlYwoll) r- ound
<br /> litir.II ASePtIS:t(5.834:Grasps:de:7T:Trench 0 Inground Pressure 0 Cesspool
<br /> Da,. , PQWTS Installation(it known): 8-3:::L _Aernbic Treatment
<br /> at tnimeit of Installation: "I 4 0"V ,-14r4'T.P--.
<br /> S .. PUNTS:Tank:/IV loolm' gallons,Soil Absorption Area:14-4 .Square Feet,List Puttied:
<br /> Ag . Existing House: years,Size of Existing House:, Square Feel,Number of Bedrooms' 4-
<br /> TY. •F PROPOSED CONSTRUCTION:
<br /> 0 • Structure 0 Replacement Structure(Fire,Tornado,Flood,Mobile Horne Replacement.etc)___
<br /> 0 -. ...?nu If remodeling,how many Sq.Ft.:_,
<br /> I
<br /> Describe Remodeling:
<br /> CI I.bathed Accessory Structure(Specify:Garage,Pole Barn,Shed,etc.): ______Wilt there be pkanbing?0 Yes 0 No
<br /> r• ,
<br /> •...mon
<br /> I 2 ..,•
<br /> addition,what Is the size of the addition; 1210 sq.ft.,Dimensions._111LX-,2-.7 Type:Cliviwi
<br /> f addition,does the addition contain bedrooms: 4 Yes 0 t4o If yes,how many: 10 n--,
<br /> otal number of bedrooms alter addition: 5 ,If addition total number of people using structure/system after addition:_i ..
<br /> 11
<br /> ( PR S sizing Is based on 2 people per bedroom using 76 gallons of water per person per day.)
<br /> • PLAN:
<br /> • • .0 a drawing of your property drawn to scale or adequately dimensioned showing lot lines,wall(s),existing POINTS and
<br /> •Ho replacement area(If known),all existing structure(s),proposed construction(dotted lines,or clearly labeled)and distances
<br /> If ••WTS Is found to be a cesspool or le found discharging onto the surface of the ground or Into ground water,surface
<br /> . ,or bedrock on the above property,this will be considered POWTS failure and the falling POWTSVAli be ordered
<br /> c• tied.
<br /> S. , is of owner or authorized Iii Is requ, • and indicates the above information Is accurate to the best of your knowledge
<br /> a • A.icates the • ills permission is given to roped the property for the purpose of this',view. c
<br /> e 77:"Zr47777""QT`- Date
<br /> 11 at least two( 11'. for review to be completed,alter required Information is received.
<br /> • es•eutercrwiehtrormApplitelkw000
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