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.•.., <br /> ` :-. Public Health I <br /> MADISON 61 DANE COUNTY Janel 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 tic. Establishments <br /> Madison,WI 53704 608 242-6435 fax <br /> www.publlchealthmdc.com <br /> Building Permit Review Application <br /> Applicant Agent) I •i///t<' �• Qt' �� CV-43t,6721 <br /> and Owner(anot apprcanq WI/ft't G� <br /> Address of Property Owner or • <br /> Authorized Agent: 61, id1+l4,cn/•Lct d.. Evotet5v i;lkk titix 53,536 <br /> AlE 1/4, $N! 1/4, Section:,.$...10 Township:Auto'pi+_11 <br /> Location of Property: t'� s � <br /> Subdivision: Bik , Lot <br /> Parcel Number: d 5 1,v1 - 3 O 3 . 'e c 0- cj) <br /> Property Address: 617 w 1 41-4,1 tcQ, RA. <br /> EXISTING HOUSE AND PRIVATE ONSITE WASTEWATER TREATMENT SYSTEM(POWTS): <br /> Type of POWTS:(check all that apply): <br /> GY Septic Tank ❑ Aerobic Treatment Unit eepage Bed 24 ' vs- ' f <br /> ❑ Seepage Trench ❑ Seepage Pit(Drywell) ❑ Mound <br /> ❑ At Grade ❑ Inground Pressure ❑ Cesspool <br /> Other(explain): <br /> Date of POWTS Installation(if known): 9/// (g?7 Owner at time of Installation: <br /> Size of POWTS:Tank: .r.(-04/0"231'4 gallons,Soil Absorption Area: Square Feet,Last Pumped: r•I -is. <br /> Age of Existing House: 60 years,Size of Existing Houser DO Square Feet,Number of Bedrooms: Si <br /> TYPE OF PROPOSED CONSTRUCTION: <br /> BYiNew 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 /> ❑ Addition <br /> if addition,what is the size of the addition: sq.ft.,Dimensions: ,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:3rbaatt. eoe4M. 16 7D s&/4' ak b4 at. '1274~. ST ter&2d .-", Si /3/t) <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 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 ind' tes the owner's permission is given to inspect the property for the purpose of this review. <br /> /?-18 --/4 <br /> O ner Author d A Date <br /> Allow at least two(2)weeks for review to be completed,after required information is received. <br /> 11/18/16-Building Permit Review Application <br />