|
S.•
<br /> •.:. Public Health
<br /> MADISON & DANE COUNTY Janel 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.com
<br /> Building Permit Review Application
<br /> Applicant(Owner or Authorized Agent) J��F� �/ / Phone:c7 f /
<br /> and OWner(ifnota applicant) U
<br /> Address of Property Owner or
<br /> Authorized Agent: /1 /// C1�,5r- ` N4" 04 1,'4 4,( f
<br /> r7r
<br /> 6 1/4, KE 1/4, Section: N Township:g 9 6,,J
<br /> Location of Property:
<br /> Subdivision: , Blk , Lot 7 #1,4s44.-(44,4 6cr '
<br /> Parcel Number: (LZG r"
<br /> ■
<br /> d ro q.. Z( � I go q —€
<br /> Property Address: �f/ Q "l 6
<br /> Il U i (IC 2tsI - ILr
<br /> EXISTING HOUSE AND PRIVATE ONSITE WASTEWATER TREATMENT SYSTEM(POWTS):
<br /> Type of POWTS: (check all that apply):
<br /> Septic Tank ❑ Aerobic Treatment Unit g Seepage Bed
<br /> ❑ Seepage Trench ❑ Seepage Pit(Drywell) ❑ Mound
<br /> ❑ At Grade ❑ Inground Pressure ❑ Cesspool
<br /> p
<br /> Other(explain): T(JM Cr Ntot/'1€3 ( 22(,C--( 1 t "14 $
<br /> Date of POWTS Installation(if known): (°-2-57-- 1 QrjG Owner at time of Installation: —
<br /> Size of POWTS:Tank: /DOG gallons, Soil Absorption Area:(0)(-:IS-Square Feet, Last Pumped: Cab b(v
<br /> Age of Existing House: 5ii years,Size of Existing House: ( 7 o 0 Square Feet, Number of Bedrooms: 3
<br /> TYPE OF PROPOSED CONSTRUCTION:
<br /> ❑ Blew Structure ❑ Replacement Structure(Fire.Tornado, Flood, Mobile Home Replacement,etc.):
<br /> Remodeling I f remodeling, how many Sq. Ft.: "r,. .2 Describe Remodeling: .A6fl 3 ;Alt46 C/ o.f...4 44,-,j, / -,'�
<br /> ❑ Detached Accessory Structure(Specify:Garage, Pole Barn,Shed,etc.): Will there be plumbing?❑Yes❑No AA'Al 1F I''Fk�J
<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: U
<br /> Total number of bedrooms after addition;3 , If addition total number of people using structure/system after addition: d .
<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 indicates the owner's permi Sion 's iv n to inspect the property for the purpose of this review. :///iih7
<br /> Owner/Authorized Agent / i i Date
<br /> Allow at least two(2)weeks for review to be completed, after required information is received.
<br /> A .20/ 7
<br /> 04/11/17-Building Permit Review Application(1)doc oW
<br /> C kte41,\T—------ f',4/)/(74,/4trlf
<br />
|