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ublic Health
<br /> 1DISON & DANE COUNTY
<br /> Healthy people and places
<br /> Janel 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 /> www.publIchealthmdc.com
<br /> Building Permit Review Application
<br /> Applicant(owner or Authorized Agent) GI„ „,,, „ and„( Er f,n r".. '^^�� phone:1Z0.72 Sc
<br /> and Owner w not applicant)ri h(nj (�,,(,fy�i� ,�1�V l �/pj/�v r L[:��
<br /> Address of Property Owner or 56-7I 20/40 1 E `t O r W)oii ""
<br /> Authorized Agent: IC� tJ
<br /> 1/4, 1/4, Section: Township:f'r, Oln
<br /> Location of Property: Fh(lcrtt V 1 t JIj( r
<br /> Subdivision:�e# Blk Lot
<br /> Parcel Number: 6LF2/ 05061 —I t � 5g-
<br /> Property � vV
<br /> Property Address: 5c7( Ali& P1 Org'oi/i WI
<br /> EXISTING HOUSE AND PRIVATE ONSITE WASTEWATER TREATMENT SYSTEM(POWTS):
<br /> Type of POWTS:(check all that apply):
<br /> Septic Tank ❑ Aerobic Treatment Unit S Seepage Bed(Z)
<br /> ❑ Seepage Trench ❑ Seepage Pit(Drywell) ❑ Mound
<br /> ❑ At Grade ❑ Inground Pressure ❑ Cesspool
<br /> Other(explain):
<br /> Date of POWTS Installation(if known):l igi & Owner at time of Installation:iNpnt1(S +AAYl Vo I b
<br /> Size of POWTS:Tank: /000 gallons,Soil Absorption Area:2082 Square Feet,Last Pumped: 201 if
<br /> Age of Existing House: 3e) years,Size of Existing House:)tt Square Feet,Number of Bedrooms: Li
<br /> TYPE OFF�PROPOSED CONSTRUCTION:
<br /> 4ttwerGatdPb ❑ Replacement Structure(Fire,Tornado,Flood,Mobile Home Replacement,etc.):
<br /> ❑ Remodeling If remodeling,how many Sq.Ft.: Describe Remodeling:.
<br /> InDetached Accessory Structure(Specify:Garage,Pole Barn,Shed,etc.):a(l,, L Will there be plumbing?❑Yes.MNo
<br /> �'}�2 r
<br /> ,� Addition /�/
<br /> if addition,what is the size of the addition' `j �f'?q,ft.,Dimensions: 114 )C(l) ,Type:
<br /> *If addition,does the addition contain bedrooms:❑Yes.[No If yes,how many: ,
<br /> Total number of bedrooms after addition: ,If addition total number of people using structure/system after addition:
<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 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 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 in • ates the ow : 's permission is given to inspect the property for the purpose of this review.
<br /> Ow er/Authoriz:+ '•ent Date
<br /> Allow at least two(2)weeks for review to be completed,after required information is received.
<br /> 9/15/2016-Building Permit Review Application 3-13.doc
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