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'� " Public Health <br /> MADISON &DANE COUNTY Janel Heinrich,MPH,MA,Director <br /> Health ld f Environmental Health Division 608 242-6515 Well&Septic <br /> Healthy eop e an aces 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 of Authorized Agent) Jim Bailweg <br /> not 608-577- <br /> and Owner Of n applicant) <br /> Address of Property Owner or Jim Ballweg <br /> Authorized Agent: <br /> 1/4, NE 1/4, Section:17 Township:Pleasant <br /> Location of Property: Springs <br /> Subdivision: , Blk , Lot <br /> Parcel Number. 0611-171-6372-8 <br /> Property Address: 2416 Wildflower Rd <br /> EXISTING HOUSE AND PRIVATE ONSITE WASTEWATER TREATMENT SYSTEM(POWTS): <br /> Type of POWTS:(check all that apply): <br /> ® Septic Tank ❑ Aerobic Treatment Unit ® Seepage Bed <br /> ❑ Seepage Trench ❑ Seepage Pit(Drywall) ❑ Mound <br /> ❑ At Grade ❑ Inground Pressure ❑ Cesspool <br /> Other(explain):Sanitary Permit Issued for a 4 bedroom house <br /> Date of POWTS Installation(if known):5-21-1973 Owner at time of Installation: <br /> Size of POWTS:Tank:1200 gal gallons,Soil Absorption Area:1000 Square Feet,Last Pumped: <br /> Age of Existing House: years,Size of Existing House: Square Feet,Number of Bedrooms: <br /> TYPE OF PROPOSED CONSTRUCTION: <br /> ❑ New 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:750-900 sq.ft.,Dimensions: ,Type:bathroom,Etc. <br /> if addition,does the addition contain bedrooms:❑Yes®No If yes,how many: <br /> Total number of bedrooms after addition:4,If addition total number of people using structure/system after addition:4 <br /> Other: Addition approved to back of house. POWTS is located in front yard. Addition not to brine total number of bedrooms greater <br /> tjian 4. Existing POWTS is sized to accommodate 4 bedrooms. <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 dearly 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 dica th owner's emission Is given to Inspect the property for the purpose of this review. <br /> C — (AN( (A/e(/11`( (° -z7-201G <br /> Owner/Authorized Agent Q A fuL L' 77'f Date <br /> Allow at least two(2)weeks for review to be completed,after required information is received. <br /> 10127116-Building Permit Review Applicalion.docx <br />