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. <br /> . <br /> Public Health Janel Heinrich, MPH,' -:-. MA, Director <br /> i l l r Environmental Health Division <br /> # 2701 International Lane, 608 242- <br /> . .ilj)` is a,:P.)°i�, 6515 W <br /> Madison,International rn 53704 Suite 204 608 243- Well&ablish <br /> Healthy people and places 0330 Lic. Establishments <br /> 608 242-6435 fax <br /> Building www publichealthmdc.com <br /> 9 Permit Review Application <br /> •Pphcant(Owner or Authonzed Agent) <br /> ndOwner(irroiOPPhcant a <br /> 'dress of Pro e ) — �b Payne-a <br /> P rty Owner or applicant(Owner-Ronald& <br /> •uthorized A Jenifer Burian) <br /> Agent: <br /> :454 Airport Rd "hone:608.566.0033 <br /> Middleton,WI 53562 <br /> oration of Property; W 1/4, <br /> NE 1/4.. <br /> Section:4 <br /> ubdivision: Township:Middleton <br /> -arcel Number: • Bik <br /> 8708/041/9270/7 Lot <br /> rope rty Address: <br /> 1454 Airport Rd-Middleton <br /> EXISTING HOUSE <br /> AND PRIVATE ONSITE WASTEWATER TREATM ENT SYSTEM(ppw►S): <br /> Type of POWTS.(check all that apply): <br /> k Septic Tank <br /> Seepage Trench Aerobic Treatment Unit <br /> At Grade Seepage Pit(D <br /> Other(explain): Ingrounq Pressure ell) Seepage Bed <br /> Date of POyyFS Installation if Mound <br /> Size of POyyTS ( known):./ 7JR Cesspool <br /> Tank: 1t)nn Owner at time of Installation:�� <br /> Age ofVVTS:Tank: gallons,Soil Absorption Area: <br /> '—'--------_years,Size of "'�-----Square Feet,Age Existing PROPOSED CO Existing House: Last Number of ed ooms I CONSTRUCTION: <br /> -"'-"---Square Feet,Number of t3edrooms:��_ <br /> XNew Structure <br /> Remodeling w Structure <br /> I f remodeling,Replacement Structure(Fire,Tornado,Flood <br /> Detached Accessory how many Sq.Ft.: .Mobile Home Replacement.etc.): <br /> Addition (Spec "-�-----Describe Remodeling: <br /> (Specify:Garage, Pole Barn, <br /> if addition; Shed,etc.): <br /> what is the size of the addition; Will there be plumbing? Yd,� <br /> if addition,does the addition contain bedrooms <br /> Total number sq.ft.,Dimensions: k <br /> Per of bedrooms after addition: o <br /> If yes, how 'Type: <br /> Other: .if addition total number of many: <br /> people using structure/system after addition: <br /> (POWYS sizing is based on 2 people per bedroom <br /> PLOT PLAN: using 75 gallons of water <br /> Provide a per Person per day.) <br /> drawing of your property drawn to scale or add <br /> pOWen above. <br /> area(if known),all existing adequately <br /> Provide above, y dimensioned showing lot lines,w <br /> g structure(s),proposed construction(dotted lines, <br /> If a PpyyrS is found to e1l(s)•existing ppyy�-S and <br /> water,or bedrock be a cesspool or clearly labeled)and distances <br /> ock on the above property,or is found discharging onto the surface of the <br /> corrected. <br /> ►ty,this Will be considered POWTS failure and the rfailing or into r <br /> Signature of owner or authorized agent ground water,surface <br /> and indicates the owner's gent is re POWYS will be ordered <br /> Permission is given toeinspect indicates p the above information f is accurate w to the <br /> the property for the purpose of this review. <br /> best of your knowledge <br /> ed Agent p <br /> Allow at least two(2)weeks for review to 1 <br /> be completed,after re Date <br /> required information is received. <br /> 828116-Building Permit Review Applicahon-8454 Airport Rd <br />