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(60?),kt-f3 - b33,3) • '.*:%• Public Health MADISON & DANE COUNTY Janel Heinrich, MPH,MA,Director Health people and places Environmental Health Division 608 242-6515 Well&Septic �'p eo p p 2701 International Lane,Suite 204 608 243-0330 Lic.Establishments Madison,WI 53704 608 242-6435 fax www.publichealthmdc.com Building Permit Review Application Applicant(Owner or Authorized Agent) Glenn Griffin Phone:608-515- and Owner(if not applicant) 0678 Address Property Owner or Authorized Agent: JD-57 C' r",I Z /1 f pt)'dcf6e. 1r w{ 3",_3E 64. SW 1/4, SW 1/4, Section:11 Township:Roxbury Location of Property: Subdivision: Blk Lot Parcel Number. 0907/113/9020/0 Property Address: 8410 County Highway Y 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 ❑ lnground Pressure ❑ Cesspool Other(explain): Date of POWTS Installation(if known):07/16/1973 Owner at time of Installation: Frank Barbian Size of POWTS:Tank: 1300 gallons,Soil Absorption Area:600 Square Feet,Last Pumped:09/10/2013 Age of Existing House: years,Size of Existing House: Square Feet,Number of Bedrooms:4 TYPE OF PROPOSED CONSTRUCTION: ❑ New Structure ❑ Replacement Structure(Fire,Tornado, Flood,Mobile Home Replacement,etc.): ❑ Remodeling If remodeling,how many Sq.Ft.: Describe Remodeling:. ❑ Detached Accessory Structure(Specify:Garage,Pole Barn,Shed,etc.): Will there be plumbing?❑Yes❑No ® Addition /ppo Cc.6 if addition,what is the size of the addition:01 sq.ft.,Dimensions: '"fl X ,Type: L �- 9/d c.f 1' Fr- `If addition,does the addition contain bedrooms: ®Yes❑ No If yes,how many: 1 -but will be removing 1 bedroom , Total number of bedrooms after addition:4,If addition total number of people using structure/system after addition:4 Other: (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 dearly 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 of owner or authorized agent is required and indicates the above information is accurate to the best of your knowledge and indicates the owner's permission i give t •nspect the property for the purpose of this review. C 57,6/16 Owner/Authorized Agent Date Allow at least two(2)weeks for review to be completed,after required information is received.