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• <br /> , %•, <br /> "• •" Public Health <br /> MADISON & DANE COUNTY Jane! 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 /> rune <br /> Applicant(Owner or Authorized Agent) <br /> and Owner(if not applicant) C ` L ��j /� Phone�0�j�y C�{� <br /> Address of Property Owner or < i/� [/ ao <br /> Authorized Agent: <br /> 5 1/4, c 6 1/4, Section: �c Township: `1 /Q. / <br /> Location of Property: U /(9.� <br /> Subdivision: , Blk , Lot <br /> Parcel Number: J� Os-la- ii q -(;g'�_`� Sr�rve �i 1 g s- <br /> Property Address: L/ �� 7 /� <br /> �r' `'z'� `erf (ICJ/- .�3 c3 <br /> EXISTING HOUSE AND PRIVATE ONSITE WASTEWATEREATMENT SYSTEM(PO S): <br /> Type of POWTS:(check all that apply): <br /> Septic Tank ❑ Aerobic Treatment Unit <br /> ❑ Seepage Bed <br /> 1E1— Seepage Trench ❑ Seepage Pit(Drywell) ❑ Mound <br /> ❑ At Grade ❑ Inground Pressure ❑ Cesspool <br /> Other(explain): GOO �f-f/ PlAit, A3 - C4} +<yC /)r <br /> Date of POWTS Installation(if known): !I �� Owner at time of Installation:NMI MM 6'• &)'/44J1 '< <br /> Size of POWTS:Tank: t0-10 Cs( gallons,Soil Absorption Area: Square Feet,Last Pumped: <br /> Age of Existing House: /0 years,Size of Existing House:Zq%5 Square Feet,Number of Bedrooms: -5 <br /> TYPE OF PROPOSED CONSTRUCTION: <br /> ❑ New Structure ❑ Replacement Structure(Fire,Tornado,Flood,Mobile Home Replacement,etc.): <br /> t1 Remodeling If remodeling,how many Sq.Ft.: Describe Remodeling:. <br /> ❑ Detached Accessory Structure(Specify:Garage,Pole Barn,Shed,etc.): Will there be plumbing?'4 I Yes❑No <br /> Ri Addition ` ,p "__))�� pp <br /> If addition,what is the size of the addition: I(3k sq.ft., Dimensions:281 i• tr�/)L ,Type: 1511, V�1 W Qa 4 <br /> *If addition,does the addition contain bedro/o,ms:' Yes❑ No If yes,how many: f Q �1 <br /> Total number of bedrooms after addition: ' , If addition total number of people using structure/system after addition: 41 � <br /> Other: P°14171. -Ffirr/f'( �'►-✓1rCP T6 y4P,P!>�� f(—8 — 2 4c /V <br /> .A> ? V7 f i r 4L 7%764 —o 7a' ) f2-tom fqq /C s 2 A- <br /> (POWTS sizing is based on 2 people per bedroom using 75 allons of water per person per day.) r—eva4stratt 4 (e I <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 <br /> (e) <br /> o is permission• gen to inapP,t the operty for the purpose of this review. _ <br /> 1 ORO OWLS <br /> Owner/Authorized Agent Date <br /> Allow at least two(2)weeks for review to be completed,after required information is received. <br /> 10/19/15-Building Permit Review Application.doc <br />