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:; • <br /> '.*:%• Public Health <br /> MADISON & DANE COUNTY Janet Heinrich,MPH,MA,Director <br /> Healthy 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(Owner or Authorized Agent) T odd Seiler Phone:228-7494 <br /> and Owner tt not applicant) <br /> Address of Property Owner or toddpseiler @gmail.com <br /> Authorized Agent: <br /> SW 1/4, NW 1/4, Section:22 Township:Blue <br /> Location of Property: Mounds <br /> Subdivision: Bik , Lot 1 <br /> Parcel Number: 0606/222/9160/7 <br /> Property Address: 2359 County Highway E <br /> EXISTING HOUSE AND PRIVATE ONSITE WASTEWATER TREATMENT SYSTEM(POWTS): <br /> Type of POWTS:(check all that apply): <br /> N Septic Tank ❑ Aerobic Treatment Unit ❑ Seepage Bed <br /> ❑ Seepage Trench ❑ Seepage Pit(Drywell) N Mound <br /> ❑ At Grade ❑ Inground Pressure ❑ Cesspool <br /> Other(explain): <br /> Date of POWTS Installation(if known):08/05/2015 Owner at time of Installation:Roland Scott <br /> Size of POWTS:Tank:1300/600 gallons,Soil Absorption Area:1375sq ft Square Feet,Last Pumped:n/a <br /> Age of Existing House:25 vrs 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 /> N Addition <br /> if addition,what is the size of the addition:1,088 sq.ft.,Dimensions:25'x 21' ,Type:ranch w future bsmt <br /> if addition,does the addition contain bedrooms:N Yes❑No If yes,how many:1 <br /> Total number of bedrooms after addition:4,If addition total number of people using structure/system after addition:6 <br /> Other:2 adults,4 children <br /> (POWTS sizing is based on 2 people per bedroom using 75 gallons of water per person per da <br /> ( 9 P P P 9 g P P P 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 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 falling 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 /> (Todd Seiler, Next Step Building&Design) 6/22/2016 <br /> r/Autho d Agent Date <br /> Allow at least two(2)weeks for review to be completed,after required information is received. <br /> 06/22/16-Building Permit Review Application 2359 Cry Hwy E.docx <br />