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RECEIVED '•'•' JAN 21 2016 'ski' PubliC Health Public Health MDC MADISON Sr DANE COUNTY Janel Heinrich, MPH, MA, Director Environmental Health Healthy people and places Environmental Health Division 608 242-6515 Well&Septic 2701 International Lane,Suite 204 608 243-0330 Lic. Establishments Madison,WI 53704 608 242-6435 fax www.publichealthmdc.com Building Permit Review Application _ 76•r4/ 9/7 .5 - Applicant(Owner or Authorized Agent) �/ f and Owner or not applicant) u 6 J/ /y F(GrlO P S 41.5"/CFtt✓hS Phone:/08 gy/_77 S 7 Address of Property Owner or / f� Authorized Agent: C,o L"77 %1u'y la /,q lei l6//- R y w 1/4, / A )Ry1/4, Section: Q Township:s�i,,)'� • i'el Location of Property: ! t� / Subdivision: , Blk , Lot Parcel Number: 0-CO /0 go g' - 0 V.? - STS-3--q Property Address: 007 7 gl yt/ /a 09)/C/ lit)). 535& 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 �/ f ❑ Ingroun ressure ❑ Cesspool Other(explain): 74 /G?'%`! 7Qli 7 Date of POWTS Installation(if known): ' O- '& Owner at time of Installation: 01 V't" Or. qStiec'TfPrs Size of POWTS:Tank;-/-/0..5-17 gallons,Soil Absorption Area: Square Feet,Last Pump-d: Age of Existing House: years,Size of Existing House: Square Feet,Number of Bedrooms: TYPE OF PROPOSED CyNSTRUCTION: ❑ New Structure lig Replacement Structure OTornado,Flood,Mobile Home Replacement,etc.): ❑ Remodeling If remodeling,how many Sq. .: 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: If addition tote number of people using structure/system after addition: . Other: Q 44 j-c --t 4�f I (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 failing POWTS will be ordered corrected. Signature • owner or authoriz d agent is required and indicates the above information is accurate to the best of your knowledge and Ind, the pe is�n Is inspect the property for the purpose of this review. �� Owner Authorized A '- t^ Date Allow at least two(2)weeks for review to be completed,after required information is received. 01100116-Building Permit Review Applicalion.doc