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Public Health <br /> MADISON & DANE cowry <br /> Healthy people and places <br /> Janet Heinrich,MPH,MA,Director <br /> 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 /> w w.publichealthmdc.corn <br /> Building Permit Review Application <br /> Applicant(Owner c Authorized Agent) n <br /> and Owner(if not applicant) /C�wr -.,,, d cON fitiNUYoN • <br /> PhoneZ,S—$L8Z <br /> Address of Property Owner or <br /> Authorized Agent: 7`sd! Voss t4 vt/L w4 S3 s-i4 L. <br /> 114, 1/4, Section: <br /> Location of Property: <br /> TownshipSto4 e• e <br /> enbdrvrslon: stir- Lot 3 Cseki 999(, <br /> Parcel Number: 05 _ Coo <br /> or l -QSLr - 3 <br /> Property Address: <br /> 7 930 Coo- 4■y L g [.r tie .v 5"- s--9.3 <br /> EXISTING HOUSE AND PRIVATE ONSITE WASTEWATER TREATMENT SYSTEM(POWTS): <br /> Type of POWTS:(check all that apply): <br /> ® Septic Tank ❑ Aerobic Treatment Unit <br /> ❑ Seepage Bed <br /> ❑ Seepage Trench El Seepage Pit(Drywell) <br /> ❑ Mound <br /> At Grade ❑ Inground Pressure <br /> Other(explain): ❑ Cesspool <br /> Date of POWTS Installation f known): /9 e S Owner at time of Installation: L 4612-L' <br /> Size of POWTS:Tank: /a<00 gallons,Soil Absorption Area: /O <br /> P CYO Square Feet,Last Pumped: /3 <br /> Age of Existing House: 7 years,Size of Existing House: 5/Z <br /> Square Feet.Number of Bedroom <br /> TYPE OF PROPOSED CONSTRUCTION: <br /> ❑ New Structure ❑ Replacement Structure(Fire.Tornado,Flood,Mobile Home Replacement,etc.): <br /> ❑ Remodeling If remodeling,how many Sq.Ft.: Describe Remodelin <br /> Ei g: <br /> Detached Accessory Structure(Specify:Garage,Pole Barn,Shed,etc.): <br /> Will there be plumbing?El Yes❑No <br /> Addition <br /> •If addition,what is the size of the addition: //y 8 Busy 4 T3Z.¢L <br /> sq.ft.,Dimensions: z c x 3 L Type; wood '414•"41 <br /> if addition,does the addition contain bedrooms:1Z Yes❑No If yes,how many: D7V N <br /> Total number of bedrooms after addition:__,If addition total number of people using structure/system after addition: r. p) a`//7 <br /> Other: <br /> /pbu t .9 u es* 7r�G+& <br /> tr <br /> (POWTS 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 Of 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 the owner's permission is given to inspect the property for the purpose of this review. c/ <br /> /Cefur�l � � J�^�/ L�'vS>".1 /ri✓v cc_ 8.7 40,-44,c,, <br /> ' <br /> Owner/Authorized Agent <br /> Date <br /> Allow at least two(2)weeks for review to be completed,after required information is received. <br /> 4/14/2016.8M6, Permit Review Application 3-13.doc <br />