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• • <br /> .�• • <br /> ':J•Public Health <br /> MADISON &DANE COUNTY Janes Heinrich,MPH,MA,Director <br /> HseIfl.,,iphje and pl c Environmental Health Division 608 242-6515 Well&Septic <br /> `°""J 2701 international Lane,Suite 204 608 243-0330 Uc.Establishments <br /> Madison,WI 53704 608 242-6435 fax <br /> www.publichealthmdc.com <br /> Building Permit Review Application <br /> Applicant(Omer or hawked Aem) Dave Koaz Phone:608-220- <br /> and Owrer(r not appsc q 3501 <br /> Address of Property Owner or 811 Collins Road,Stoughton,WI <br /> Authorized Agent: <br /> SW 1/4, SW 1/4, Section:15 Township:Dunkirk <br /> Location of Property: <br /> Subdivision: , Bic Lot <br /> Parcel Number: 0511-153-9390-4 <br /> Property Address: Same as above <br /> • <br /> EXISTING HOUSE AND PRIVATE ONSITE WASTEWATER TREATMENT SYSTEM(POWTS): <br /> Type of POWTS:(check all that apply): <br /> ® Septic Tank ❑ Aerobic Treatment Unit ❑ Seepage Bed <br /> ❑ Seepage Trench ® Seepage Pit(Drywein ❑ Mound <br /> ❑ At Grade ❑ Irground Pressure ❑ Cesspool <br /> Other(explain):Sanitary oemnit No.21812/Dane 81-0404 issued 10-22-1981 for 3-bedroom house. <br /> Date of POWTS Installation(If known):10-22-1981 Owner at time of installation: <br /> Size of POWTS:Tar*1000 gallons,SON Absorption Area:_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 /> ❑ New Structure ❑ Replacement Structure(Fire,Tornado,Flood,Mobile Home Replacement,etc.): <br /> ❑ Remodeling If renwdeNng,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:300 sq.ft.,Dimensions:15 x 20 ,Type:bedroom remodel <br /> *If addition,does the addition contain bedrooms:®Yes❑No If yes,how many,1 <br /> Total number of bedrooms after addition:,/,If addition total comber of people using structure/system after adctlion:0 . <br /> Other.Permit Issued for a 3-bedroom ihouse. Owner indicates that total number of bedroom after addition will be 3. <br /> (POWTS sizing Is based on 2 people per bedroom using 76 gallons of water per person per day.) <br /> PLOT PLAN: <br /> Provide a drawing of your property drawn to scale or adequately dknensioned showing lot lines,well(s),existing POWTS and <br /> POWTS replacement area(If known),all existing sbucbure(s),proposed construction(dotted lines,or dearly labeled)and distances <br /> between above. <br /> if a POWI'S 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 owr►ert�penn�aglorh is� M� the property for the purpose of this review. <br /> OwneNAut prized^_\///Agent �`v' Data <br /> Allow at least two(2)weeks for review to be complleeted,after required information is received. <br /> 4° °'((6$736 07/1715 rdro Pane R.NwAppralbndoo l � � / <br /> (c—/PC fl- 44y f` ®44f c i <br />