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..t, ': "' Public Health MADISON St DANE COUNTY Janet Heinrich, MPH,MA, Director Healthy people and places Environmental Health Division 608 242-651 5 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 Applicant(owner or Authorized Agent) 4 r./0 Phone:608-837- e and Owner(it not applicant) Jeremy wed,Jennings&Woldt 6312 Address of Property Owner or Authorized Agent: SE 1/4, NW 1/4, Section:29 Township:Bristol Location of Property: Subdivision: Blk Lot 33 Moonlight Circle, Parcel Number: 0911-292-7023-6 Property Address: 6781 Moonlight Circle 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 El Seepage Pit(Drywell) ❑ Mound ❑ At Grade ❑ Inground Pressure ❑ Cesspool Other(explain):Both primary and reserve drainfields were installed 7-27-1992 with switching valve. Date of POWTS Installation(if known):7-27-1992 Owner at time of Installation: Size of POWTS:Tank:1000 gallons,Soil Absorption Area:(2)990 Square Feet,Last Pumped: Age of Existing House: years,Size of Existing House: Square Feet,Number of Bedrooms:3 TYPE OF PROPOSED CONSTRUCTION: ❑ New Structure ❑ Replacement Structure(Fire,Tornado,Flood,Mobile Home Replacement,etc.): El 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 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:1 Total number of bedrooms after addition:4,If addition total number of people using structure/system after addition:5 . • Other:System sized for 3-bedrooms,OR,6 persons. One additional bedroom is OK if occupance of house is less than 6 persons. (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 of owner or authorized agent is required and indicates the above information is accurate to the best of your knowledge and in at t e owner's ermisston is given to inspect the property for the purpose of this review. C �� SA1 1 l� !,4 �.—1 e-20/6 • Owner/Authorized fCgen( Date Allow at least two(2)weeks for review to be completed,after required information is received. O8r18r168uilding Permit Review Application doc