Laserfiche WebLink
Public Health <br /> MADISON 61: DANE COUNTY <br /> Healthy people and places <br /> Janet Heinrich,MPH,MA,Director <br /> Environmental Health Division 808 242-8515 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(Owner or Authorized Agent) Rawer 4'S t.g d 4143 t wc,•C ou • tC 44e•.Z C S -Sal L <br /> and Owner(n not appucant) �$1Ai a%1rftt-a q,�,� /14A, �B7N 4 N.aso.-+ <br /> Phone:eels. <br /> Address of Properly-Aweec.ec Ade Z3'Y�/47/ <br /> Authorized Agent: 7YL/ f 5$ 1 4,4.c w A y ivl AMC e.f'O.v G✓G fdS6 (o(si <br /> 1/4, 1/4, Section: Township: sf 4, r2(er <br /> Location of Property: <br /> Subdivision: , Bik Lot / CS-++ /y093 <br /> Parcel Number: 03 8/670 9/3a 3/2 o 78/8 <br /> Property Address: <br /> 7 --5/teA/4r r e$1 Per sorsz 8 <br /> EXISTING HOUSE AND PRIVATE ONSITE WASTEWATER TREATMENT SYSTEM(POWTS): <br /> Type of POWTS:(check all that apply): <br /> g Septic Tank ❑ Aerobic Treatment Unit <br /> ❑ Seepage Bed <br /> ❑ Seepage Trench ❑ Seepage Pit(Drywell) <br /> ® Mound <br /> At Grade Inground Pressure ❑ Cesspool <br /> �� <br /> Other(explain): A X,..<f ¢• 29s4..r <br /> Date of POWTS Installation(if known): .T4.vC /!9' Owner at time of Installation: 0 i✓ETic <br /> Size of POWTS:Tank: /moo ,'11.0 gallons,Soil Absorption Area: /Zoo Square Feet,Last Pumped: <br /> Age of Existing House: /7 years,Size Of Existing House: Square Feet,Number of Bedrooms: 3 <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 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: //`O9 sq.ft.,Dimensions:tat 4 r'Ac.Nes Type: 9 4.4,t; <br /> if addition,does the addition contain bedrooms:❑Yes®No If yes,how many: /VDT.A} As.C4 4LE <br /> Total number of bedrooms after addition:1/C,If addition total number of people using structure/system after addition: Z <br /> Other: <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 agequatey 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 the owner's permission is given to inspect the property for the purpose of this review. <br /> Ro0,e-'44239.4+434 4i.+J/Au c. B : �rre„C,�h E• .440j '1/l1l/6 <br /> Owner/Authorized Agent Date <br /> Allow at least two(2)weeks for review to be completed,after required information is received. <br /> 4/14/2016-Budding Permit Review Application 3-13.doc <br />