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'o r- Public Health MADISON & DANE COUNTY Janet Heinrich, MPH, MA, Director Health le and laces Environmental Health Division 608 242-6515 Well&Septic Healthy people p 2701 International Lane,Suite 204 608 243-0330 Lic. Establishments Madison,WI 53704 608 242-6435 fax www.publichealthmdc.com Building Permit Review Application Applicant(Owner or Authorized Agent) Mark Fredenburg Phone:235-7282 and Owner(if not applicant) Address of Property Owner or Authorized Agent: 1/4, 1/4, Section:4 Township:Cottage Location of Property: Grove Subdivision: , Blk Lot Parcel Number: 0711-041-8110-5 Property Address: 2445 Gaston Road EXISTING HOUSE AND PRIVATE ONSITE WASTEWATER TREATMENT SYSTEM(POWTS): Type of POWTS:(check all that apply): ® Septic Tank ❑ Aerobic Treatment Unit ❑ Seepage Bed ® Seepage Trench ❑ Seepage Pit(Drywell) ❑ Mound ❑ At Grade ❑ Inground Pressure ❑ Cesspool Other(explain):600 gallon pump chamber. System sized for a 3-bedroom house. Date of POWTS Installation(if known):9-24-1993 Owner at time of Installation: Size of POWTS:Tank: 1000 gallons,Soil Absorption Area:750 Square Feet,Last Pumped: Age of Existing House: years,Size of Existing House: Square Feet,Number of Bedrooms: TYPE OF PROPOSED CONSTRUCTION: ❑ New Structure ❑ Replacement Structure(Fire,Tornado,Flood,Mobile Home Replacement,etc.): ❑ Remodeling If remodeling,how many Sq.Ft.: Describe Remodeling:. ❑ Detached Accessory Structure(Specify:Garage,Pole Barn,Shed,etc.): Will there be plumbing?❑Yes❑ No Addition *If addition,what is the size of the addition: sq.ft.,Dimensions: ,Type: *If addition,does the addition contain bedrooms:❑Yes®No If yes,how many: Total number of bedrooms after addition:3, If addition total number of people using structure/system after addition: Other:Septic system sized for a three bedroom house,inspected and approved 9-24-1993,Permit Dane 93-0371. No objection to non-bedroom addition located on west side of house provided that minimum setbacks from septic syste are maintained. (POWTS sizing is based on 2 people per bedroom using 75 gallons of water per person per day.) PLOT PLAN: Provide a drawing of your property drawn to scale or adequately dimensioned showing lot lines,well(s),existing POWTS and POWTS replacement area(if known),all existing structure(s),proposed construction(dotted lines,or clearly labeled)and distances between above. If a POWTS is found to be a cesspool or is found discharging onto the surface of the ground or Into ground water,surface water,or bedrock on the above property,this will be considered POWTS failure and the falling POWTS will be ordered corrected. Signature of owner or authorized agent is required and indicates the above information is accurate to the best of your knowledge an ' is s e owner's permi sion is given to inspect the property for the purpose of this review. Allow at least two(2)weeks for review to be completed,after required information is received. C<io( 10/01/15-Building Permit Review Application.docx �l