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::-,:-- - Public Health
<br /> Janel Heinrich, MPH, MA, Director
<br /> Healthy people and places Environmental Health Division 608 242-6515
<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)
<br /> — - -- Phone: rt
<br /> and Owner(ii not applicant) t °` f ".; y.- L yes e ,s' 7,P
<br /> •Address of Property Owner or F7C 7/ 1
<br /> Authorized Agent: / e / /'?/ 77°t
<br /> 1/4, 1/4, Section: t Township 7q( t f}f
<br /> Location of Property:
<br /> Subdivision ' 7d1 Blk Lot /
<br /> _ .afv,fi t s /
<br /> Parcel Number: Ldr° J f yf/.
<br /> Property Address: -` 1 H
<br /> fir—
<br /> EXISTING HOUSE AND PRIVATE ONSITE WASTEWATER TREATMENT SYSTEM(POWTS):
<br /> Type of,POWTS: (check all that apply):
<br /> p Septic Tank ❑ 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: r: j a f A:,,"
<br /> Size of POWTS:Tank: 5f=' `16„> gallons, Soil Absorption Area: Square Feet, Last Pumped:
<br /> Age of Existing House: :Y' years, Size of Existing House: /t / 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: r,/ sq. ,r
<br /> ft., Dimensions: t,,-a 1 ,Type: � 1:c a t- `e z j4
<br /> *If addition,does the addition contain bedro9ms: ❑ Yes g 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 /> (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,e ner or authorized agent is required and indicates the above information is accurate to the best of your knowledge
<br /> and indic- 's the o ner'sper[ issin i,sglven tninspect the property for the purpose of this review.
<br /> � °r o t
<br /> K
<br /> Owner/Authorized Agent / Date
<br /> Allow at least two(2)weeks for review to be completed, after required information is received. ,..;( w
<br /> tt t 1
<br /> 04/20"7-Building Permit Review Application(lac
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