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• <br /> •.•«• <br /> " " P <br /> .s;a* <br /> Public Health <br /> MADISON Ex DANE COUNTY lanel Heinrich, MPH, MA, Director <br /> Healthy people and places Environmental Health Division 608 242-651 5 <br /> 2300 S Park St, Rm 2010 608 242-6435 fax <br /> Madison,WI 53713 www.publichealthmdc.. <br /> o <br /> m <br /> Building Permit Review Application � <br /> Applicant(Owner or Authorized Agent) (� Pho j lJ <br /> and Owner(if not applicant) - - <br /> Address of Property Owner or j <br /> Authorized Agent: 97/g /(.Cr sC //r (9,4-'7,r (/ <br /> 1/4, 1/4, Section: Township: <br /> Location of Property: <br /> Subdivision: ) , Blk , 2 Lot <br /> Parcel Number: 0-C2 6_5N --;g 2 ...?/....3 o -2 <br /> Property Address: Z/7/d 1✓-6)-k-- ,c_7f .... 0,/-s:, (.✓/ S-; S <br /> 1 r <br /> EXISTING HOUSE AND PRIVATE ONSITE WASTEWATER TREATMENT SYSTEM(POWTS): <br /> Type of POWTS:(check all that apply): <br /> JZI Septic Tank <br /> ❑ Aerobic Treatment Unit ❑ Seepage Bed <br /> ❑ Seepage Trench ❑ Seepage Pit(Drywell) ❑ Mound <br /> ❑ At Grade ❑ Inground Pressure ❑ Cesspool <br /> Other(explain): <br /> Date of POWTS Installation(if known): Owner at time of Installation: <br /> Size of POWTS:Tank: gallons,Soil Absorption Area: 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 /> 8- Addition <br /> 2- '22/2 yp . ;�,�"�- , �t� <br /> *If addition,what is the size of the addition:, 514- 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: <br /> (POWYS 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 indicates th ner's permission is given to inspect the property for the purpose of this review. <br /> -------- 2 /1,c;10 <br /> Owf9ra1 Date <br /> Allow least two(2)weeks to be completed,after required information is received. <br /> 02/15/17-Building Permit Review Application.doc <br />