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qifr s D 4/&( <br /> • <br /> •' •' Public Health <br /> MADISON bt DANE COUNTY panel 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 5371 3 www.publichealthmdc.com <br /> Building Permit Review Application <br /> Applicant(Owner or Authorized Agent) � <br /> and Owner(if not applicant) 1"' � I� )J Phone: 357-41> <br /> Address of Property Owner or <br /> Authorized Agent: LET EX) C .S 5 tr-)6 sLuo eeictbeu (0!5.--„s <br /> .s-9 <br /> 1/4, 1/4, Section: Township:f,(J <br /> Location of Property: p k I I /��k j t-��- <br /> Subdivision: /J Bl Lot <br /> Parcel Number: oq II - 303 - Zco( —0 <br /> Property Address: / '2/3 6546 ��S t W c!/� IL, Lt.�l3 (/clE <br /> EXISTING HOUSE AND PRIVATE ONSITE WASTEWATER TREATMENT SYSTEM(POWTS): <br /> Type of POWTS:(check all that apply): <br /> 'Et_ Septic Tank ❑ Aerobic Treatment Unit ❑ Seepage Bed <br /> ❑ Seepage Trench ❑ Seepage Pit(Drywell) a Mound <br /> ❑ At Grade ❑ Inground Pressure ❑ <br /> Cesspool <br /> Other(explain):S'A a54.Q e6-M(? (3-201( AP/0 ,o R <br /> BtrpD,,vo/r- <br /> Date of POWTS Installation(if known): `'t— ("7— �I Z Owner at time of Installation: <br /> Size of POWTS:Tank: (2-'84 gallons, Soil Absorption Area 4141-4A0 Square Feet, Last Pumped: <br /> Age of Existing House: 62 ` AS years,Size of Existing House: `7/(''(_"(.\ 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: /f sq.ft., Dimensions: ,Type: <br /> *If addition,does the addition contain bedrooms:XYes❑ No If yes, how many: / <br /> Total number of bedrooms after addition: y , If addition total number of people using structure/system after addition: <br /> Other: ,C� t{C' ( PA-(1-6."6. <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 Vindicates the own 's permission is given to inspect the property for the purpose of this review. <br /> _ _'-l_�_ // <br /> Owner/Authorized Agent Date <br /> Allow at least two(2)weeks for review to be completed,after required information is rec ive <br /> 41PP°U6D S 22/ 29(? X714//g7--- <br /> 05/19/17-Building Permit Review Application.doc f-A,/ ( <br />