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• <br /> '° •• Janel Heinrich,MPH,MA,Director <br /> ° Public Health Environmental Health Division 608242-6515 <br /> 2300 S Park St,Rm 2010 608 242-6435 fax <br /> MADISON & DANE COUNTY Madison,WI 53713 www.publichealthmdc.com <br /> Healthy people and places Building Permit Review Application <br /> Applicant(owner or Aul ) Agent) q Phone: 553 w and Owner(•not applicant) <br /> Address of Property Owner or t <br /> Authorized Agent: 3 .�, (xg <br /> 1/4, ' 1/ , Section: Township: <br /> Location of Property: <br /> Subdivision: , Blk Lot <br /> Parcel Number: cF-62/^Slo <br /> Property Address: BI t'i 4-1 n <br /> V �l � <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): <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 /> EL Addition ■ <br /> if addition,what is the size of the additior ` *7 sq.ft.,Dimensions: / ,X2� ,Type: <br /> 'If addition,does the addition contain bedroirnslig 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 /> (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 •f your nowledge <br /> �a•din•I tes the owner's permission is given to Inspect the property for the purpose of this review. <br /> t. <br /> • ner/•,L ho e. •geri D: e <br /> Allow at east two(2)weeks for review to be completed,after required information Is received. <br /> 5/15/2017-Building Permit Review Application 3-13.doc <br /> • <br />