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`•' "i' Public Health <br /> MADISON k DANE: COUNTY )anel Heinrich,MPH, MA. Director <br /> Healthy people and places Environmental Heaitn Division - 600 242-5515" <br /> 2300 5 Park 5t, Rrn 2010 603 24 2-64 35 fax <br /> Madison,WI 53713 wwwpublicheelthmdc-corn <br /> Building Permit Review Application <br /> FP <br /> A licant`o'rerc (608) <br /> c Paul kxxrfie Phone:438-7432 <br /> and Owner.t rCr a�Irar, <br /> Address of Property Owner or <br /> 3725 Shiloh Rd DeForest WI 53532 <br /> Authorized Agent. <br /> NE 114. SE 1/4, Section 03 Township:Burke <br /> Location of Property: _ <br /> Sub estrn Stony glk Lot 45 <br /> Ridge, <br /> Parcel Number. 0510`03 4`0:4596 <br /> Property Address: 3725 Sholoh Rd <br /> EXISTING HOUSE AND PRIVATE ONSITE WASTEWATER TREATMENT SYSTEM(POWTS): <br /> Type of POWTS (check all that apply;i• <br /> Septic Tank ❑ Aerobic Treatment Unit ❑ Seepage Bed <br /> ❑ Seepage Trench ❑ Seepage Pit(Drywell) ❑ <br /> ❑ At Grade ❑ Irgreund Pressure ❑ Cesspool <br /> Other(explain): <br /> Date of POWTS Installation(if known):11/0211979 Owner at time of Installation:Don Simon Inc. <br /> Size of POWTS:Tank: 1000 q.Al Gallons,Soil Absorption Area U40 Square Feet,Last Pumped O&23/2015 <br /> Age of Existing House:1979 years.Size of Existing House: Square Feet.Number of Bedrooms:3 <br /> TYPE OF PROPOSED CONSTRUCTION: <br /> ❑ New Structure ❑ Repo-acement Structure(Fire,Tornado.Flood,Mobile Home Replacement,etc <br /> Remocleling If remodetinq noir.,many sq R 480 Describe Remodeliro Garage made into great roomllaundry roorr bathroom <br /> ❑ Detached Accessory Structure(Specify Garage,Pole Barn.Shed;etc). Will there be phirabing?2)Yes❑No <br /> ❑ Addition <br /> If addition,what is the si e of the addition____T__sq ft. Dimensions: -- _—_-- .Type: <br /> if <br /> `If addition,dots the addeon cc :tun bedrooms ❑Yes 0 No If yes,how many <br /> Total number of bedrooms after addrtion. .If addition total number of people using structure S stem 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 fines,well(s).existing POWTS and <br /> POWTS replacement area(if knrawr),ail existing structure(s),proposed construction(dotted fines,cr dearly 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 authorised agent i5 required and indicates the above information is accurate to the best of your knowledge <br /> and indicates the owners permission is given to inspect the propeny for the purpose of this review <br /> Pa1A . Kj •14);_>" 6/28/17 <br /> Owner/Authorized Agent Date <br /> Allow at least M (2)weeks for review to be Comp=eted after required Information is received <br /> .s 2 7-cricnei <br />