Laserfiche WebLink
U <br /> e oo4) <br /> ''1 Public Health <br /> MADISON ST DANE COUNTY Thomas L.Schlenker,MD,MPH,Director <br /> ___ ^w r�_ <br /> Healy 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 /> Applicant <br /> erofn(Owner orAumodxedAaent) I ` 1 i LAA a „ -5 Phone:g'c)-4LL"7� <br /> andOWRerpfnotapplicnnl) _ JJtJV <br /> Address of Property Owner or <br /> Authorized Agent: 6131 V r Wn h S tJ It V A0E A.ee VV+' i 7 <br /> NG 114, SV\f 1/4, Section: ©"{ Township:0 <br /> Location of Property: - - <br /> Subdivision: Bik , Lot <br /> Parcel Number: 0 14- (O t d--c'1 OO \— <br /> 4 : v <br /> Property Address: ,�'c AVO��flt (� <br /> EXISTING HOUSE AND PRIVATE ONSITE WASTEWATER TREATMENT SYSTEM(POWTS): <br /> Type of POWTS:(check all that apply): <br /> X iSeptic Tank ❑ Aerobic Treatment Unit ❑ Seepage Bed <br /> Seepage Trench ❑ Seepage Pit(Drywall) ❑ Mound <br /> ❑ At Grade ❑ inground Pressure ❑ Cesspool <br /> Oilier(explain): <br /> Date of POWTS Installation(If known): 03/93 Owner at time of Installation: . , . A * e 1. <br /> Size of POWTS:Tank: 1045 O gallons,Soli Absorption Area:900 Square Feet,Last Pumped: a- t 9 " I ' <br /> Age of Existing House: Z3 years,Size of Existing Houss:,lc 1 to Square Feet,Number of Bedrooms: .. <br /> TYPE OF PROPOSED CONSTRUCTION: <br /> ❑ New Structure "jiiV.. Replacement Structure 0 Tornado,Flood,Mobile Home Replacement,ele.):_ }11,�( J-e_. <br /> ❑ Remodeling if remodeling,how many Sq.Ft,: Describe Remodeling:. <br /> ❑ Detached Accessory Structure(Specify:Garage,Pole Barn,Shed,etc.): Will there be plumbing?0 Yea❑No <br /> ❑ Addition <br /> 11 addition,what is the size of the addition: sq.It.,Dimensions: ,Type: <br /> *if addition,does the addition contain bedrooms:❑Yes❑No if yes,how many: , <br /> Total number of bedrooms after addition: ,if addition total number of people using siructure/system after addition: . <br /> Other: <br /> (POWYS 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 struclure(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 permission Is given to Inspect the property for the purpose of this review. <br /> UJZ <br /> Owner ul toe" ,gent Date <br /> Allow at least two(2)weeks for review to be completed,after required Information Is received. <br /> 091241te•Documenll <br />