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• <br /> .. %., . <br /> '0�"' Public Health <br /> MADISON & DANE COUNTY Jane! Heinrich, MPH, MA, Director <br /> Healthy people�e and places Environmental Health Division _w 608 242-651 5 Well&Septic <br /> r 2701 International Lane,Suite 204 608 243-0330 Lic. Establishments <br /> Madison,Wi 53704 608 242-6435 fax <br /> www.pubiichealthmdc.com <br /> Building Permit Review Application <br /> Applicant(owner or Authorized Agent) Son Moore-builder Phone:608-209- <br /> and Owner(if not scant) 1395 <br /> Address of Property Owner or 4075 Vilas Road <br /> Authorized Agent: <br /> NE 1/4, SE 1/4, Section:17 Township:Cottage <br /> Location of Property: <br /> Grove <br /> Subdivision: , Bik Lot <br /> Parcel Number: 0711-163-8650-5 <br /> Property Address: 4075 Vilas Road <br /> EXISTING HOUSE AND PRIVATE ONSITE WASTEWATER TREATMENT SYSTEM(POWTS): <br /> Type of POWTS:(check all that apply): <br /> ': Septic Tank ❑ Aerobic Treatment Unit ii Seepage Bed <br /> ❑ Seepage Trench • ❑ Seepage Pit(Drywall) ❑ Mound <br /> ❑ At Grade i ❑ Inground Pressure ❑ Cesspool <br /> Other(explain):Puma Chamber i <br /> Date of POWTS Installation(if known):5-15-1996 Owner at time of Installation: <br /> Size of POWTS:Tank:1000 gallons,Soil Absorption Area:945 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 /> 0 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:528 , sq.ft.,Dimensions: 16 x 33 ,Type:Family Room <br /> elf addition,does the addition contain bedrooms: El Yes❑No If yes,how many: , <br /> Total number of bedrooms after addition: , If addition total number of people using structure/system after addition: . <br /> Other:Septic system installed 5-15-1996 as per permit W-0188245925 for a 3-bedroom house,No obiection to family room addition <br /> that will extend the house 16 feet to the north. <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 /> Signature of owner or authorized agent is required and indicates the above information is accurate to the best of your knowledge <br /> and indicates the owner's permiss' is g n to spect the p operty for the purpose of this review. <br /> /VI*1/6/)- —a <br /> Owner/Authorized Agent ,1:4-"Y( /4s/ ./7-r Date <br /> Allow at least two(2)weeks for review to be completed,after required information is received. <br /> 09/03115-Building Permit Review Application.docn <br />