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':•y. Public Health <br /> MADISON Ex DANE COUNTY lane)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 unots Authorized <br /> lc applicant) AIM,o-i 4- E. 1 nc Phone. <br /> and Owner pr not•pp9c•nl> v 6 <br /> Address of Property Owner or .G� �/ <br /> Authorized Agent: o 47 D f h 4/S 2 r A t p?z,7 1,4 4444 5:3 5 40 <br /> s v 1/4, ,+ 1,, 1/4, Section: '3 -v._54110101p: 6 <br /> Location of Property: `� / �;7 � <br /> r7" <br /> Subdivision: Bik Lot ►� <br /> /- <br /> Parcel Number: 00'1 / p $0-7 — 03 - ro <br /> Property Address: <br /> EXISTING HOUSE AND PRIVATE ONSITE WASTEWATER TREATMENT SYSTEM(POWTS): <br /> Type of POWTS:(check all that apply): <br /> X. Septic Tank ❑ Aerobic Treatment Unit ❑ Seepage Bed <br /> ❑ Seepage Trench ❑ Seepage Pit(Drywell) pit, Mound <br /> ❑ At Grade ❑ Inground Pressure ❑ Cesspool <br /> Other(explain): <br /> Date of POWTS Installation Of known): e211500, Owner at time of installation: YJ-1'P <br /> Size of POWTS:Tank: /000 gallons,Soil Absorption Area:Son Square Feet,Last Pumped: /G—/— /Z <br /> Age of Existing House: /r f years,Size of Existing House:A SIG Square Feet,Number of Bedrooms: <br /> TYPE OF PROPOSED CONSTRUCTION: <br /> ❑ New Structure ❑ Replacement Structure(Fire,Tornado,Flood,Mobile Home Replacement,etc.): <br /> El Remodeling If remodeling,how many Sq.Ft.: Describe Remodeling:. <br /> O Detached Accessory Structure(Specify:Garage,Pole Barn,Shed,etc.): Will there be plumbing?❑Yes❑No <br /> 14, Addition <br /> if addition,what Is the size of the addition: .l.( sq.ft.,Dimensions: rt-a 4-.9-re ,Type: BED/2.p4M <br /> if addition,does the addition contain bedrooms:13I,Yes❑No If yes,how many: <br /> Total number of bedrooms after addition: 4 ,If addition total number of people using structure/system after addition:.¢ <br /> Other: <br /> (POWTS sizing Is based on 2 people per bedroom ustng 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 /> 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 falling 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 Indict s the ner's p rmission Is given to Inspect the property for the purpose of this review. <br /> d y_ 7-.2 <br /> Owner/Au ed Agent Date <br /> Allow at least two(2)weeks for review to be completed,after required information Is received. <br /> 0910411S.Buedirp Permll Review Apple:aeon.doe <br />